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Questions and Answers
What is the primary purpose of Continuous Positive Airway Pressure (CPAP)?
What is the primary purpose of Continuous Positive Airway Pressure (CPAP)?
What are the indications for using CPAP?
What are the indications for using CPAP?
What is a contraindication for using Supraglottic airway devices?
What is a contraindication for using Supraglottic airway devices?
What is an advantage of Supraglottic airway devices?
What is an advantage of Supraglottic airway devices?
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What is the management technique for shoulder dystocia that involves moving the buttocks off the end of the bed and flexing the thighs upward?
What is the management technique for shoulder dystocia that involves moving the buttocks off the end of the bed and flexing the thighs upward?
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What term is used to describe shoulder dystocia where the baby's head delivers but the body does not?
What term is used to describe shoulder dystocia where the baby's head delivers but the body does not?
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What is the recommended action if unable to slip the nuchal cord over the infant’s head?
What is the recommended action if unable to slip the nuchal cord over the infant’s head?
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Which medication is used to treat eclampsia and hypertension in pregnancy but not recommended for pre-eclampsia due to potential toxicity?
Which medication is used to treat eclampsia and hypertension in pregnancy but not recommended for pre-eclampsia due to potential toxicity?
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What is a benefit of intramuscular (IM) drug administration over the subcutaneous (SQ) route, especially in critical patients?
What is a benefit of intramuscular (IM) drug administration over the subcutaneous (SQ) route, especially in critical patients?
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Which method delivers medication as a fine aerosol into the nose, resulting in a broader distribution and increased bioavailability?
Which method delivers medication as a fine aerosol into the nose, resulting in a broader distribution and increased bioavailability?
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What is the goal of fluid resuscitation?
What is the goal of fluid resuscitation?
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Which condition is considered a common STEMI imposter?
Which condition is considered a common STEMI imposter?
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What is the formula for Mean Arterial Pressure (MAP)?
What is the formula for Mean Arterial Pressure (MAP)?
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What does tranexamic acid (TXA) do?
What does tranexamic acid (TXA) do?
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What is the first step in the trauma field triage decision scheme?
What is the first step in the trauma field triage decision scheme?
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What does permissive hypotension allow?
What does permissive hypotension allow?
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What does implanted pacemakers mimic on EKG?
What does implanted pacemakers mimic on EKG?
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What is used to differentiate STEMI from STEMI imposters?
What is used to differentiate STEMI from STEMI imposters?
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When should prompt transport be provided for breech presentation?
When should prompt transport be provided for breech presentation?
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What does limb presentation in childbirth indicate?
What does limb presentation in childbirth indicate?
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What does prolapsed cord indicate in childbirth?
What does prolapsed cord indicate in childbirth?
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What does shoulder dystocia indicate in childbirth?
What does shoulder dystocia indicate in childbirth?
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What is the potential consequence of reintroducing high concentrations of oxygen to cells that have been functioning anaerobically?
What is the potential consequence of reintroducing high concentrations of oxygen to cells that have been functioning anaerobically?
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How can Return of Spontaneous Circulation (ROSC) be recognized in cardiac arrest patients?
How can Return of Spontaneous Circulation (ROSC) be recognized in cardiac arrest patients?
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What is the recommended SpO2 level for post-cardiac arrest patients?
What is the recommended SpO2 level for post-cardiac arrest patients?
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What should be maintained within the range of 35-40mm/Hg for post-cardiac arrest patients?
What should be maintained within the range of 35-40mm/Hg for post-cardiac arrest patients?
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What should be monitored and managed in hemodynamically unstable post-cardiac arrest patients?
What should be monitored and managed in hemodynamically unstable post-cardiac arrest patients?
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What is an acceptable airway management method during CPR?
What is an acceptable airway management method during CPR?
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What should be attached to airways and monitored for signs of ROSC?
What should be attached to airways and monitored for signs of ROSC?
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What may cause pediatric cardiac arrest?
What may cause pediatric cardiac arrest?
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What are potential causes of Congestive Heart Failure (CHF)?
What are potential causes of Congestive Heart Failure (CHF)?
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What are common presentations/signs/symptoms of CHF?
What are common presentations/signs/symptoms of CHF?
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What are the contraindications for Nitroglycerin use?
What are the contraindications for Nitroglycerin use?
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What is a disadvantage of minimal equipment required for intubation?
What is a disadvantage of minimal equipment required for intubation?
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What is an advantage of Endotracheal Tubes (ETT)?
What is an advantage of Endotracheal Tubes (ETT)?
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What should be avoided unless necessary when suctioning the airway in newborns?
What should be avoided unless necessary when suctioning the airway in newborns?
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What does End tidal CO₂ (ETCO₂) measurement reflect?
What does End tidal CO₂ (ETCO₂) measurement reflect?
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In which patients can measuring ventilation provide information on chest compressions and probability of successful resuscitation?
In which patients can measuring ventilation provide information on chest compressions and probability of successful resuscitation?
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What does a normal ETCO₂ and capnography waveform consist of?
What does a normal ETCO₂ and capnography waveform consist of?
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What is the recommended oxygen administration for patients with suspected acute coronary syndrome or stroke based on SpO₂ levels?
What is the recommended oxygen administration for patients with suspected acute coronary syndrome or stroke based on SpO₂ levels?
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What is a disadvantage of Endotracheal Tubes (ETT)?
What is a disadvantage of Endotracheal Tubes (ETT)?
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What can be measured using physiology of CO₂?
What can be measured using physiology of CO₂?
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What can reintroducing high concentrations of oxygen to cells that have been functioning anaerobically cause?
What can reintroducing high concentrations of oxygen to cells that have been functioning anaerobically cause?
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How should post-cardiac arrest patients maintain their SpO2 levels?
How should post-cardiac arrest patients maintain their SpO2 levels?
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What should be monitored and managed in hemodynamically unstable post-cardiac arrest patients?
What should be monitored and managed in hemodynamically unstable post-cardiac arrest patients?
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What is a potential cause of cardiac arrest that should be managed?
What is a potential cause of cardiac arrest that should be managed?
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What is an important consideration for airway management during cardiac arrest?
What is an important consideration for airway management during cardiac arrest?
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What should capnography be monitored for during cardiac arrest?
What should capnography be monitored for during cardiac arrest?
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What is a potential disadvantage of minimal equipment required for intubation?
What is a potential disadvantage of minimal equipment required for intubation?
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What is an advantage of Endotracheal Tubes (ETT)?
What is an advantage of Endotracheal Tubes (ETT)?
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What should be avoided unless necessary when suctioning the airway in newborns?
What should be avoided unless necessary when suctioning the airway in newborns?
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What does End tidal CO₂ (ETCO₂) measurement reflect?
What does End tidal CO₂ (ETCO₂) measurement reflect?
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What can be measured using physiology of CO₂?
What can be measured using physiology of CO₂?
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In which patients can measuring ventilation provide information on chest compressions and probability of successful resuscitation?
In which patients can measuring ventilation provide information on chest compressions and probability of successful resuscitation?
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What does a normal ETCO₂ and capnography waveform consist of?
What does a normal ETCO₂ and capnography waveform consist of?
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What is the recommended oxygen administration for patients with suspected acute coronary syndrome or stroke based on SpO₂ levels?
What is the recommended oxygen administration for patients with suspected acute coronary syndrome or stroke based on SpO₂ levels?
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What should be maintained within the range of $35-40$ mm/Hg for post-cardiac arrest patients?
What should be maintained within the range of $35-40$ mm/Hg for post-cardiac arrest patients?
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What should be monitored and managed in hemodynamically unstable post-cardiac arrest patients?
What should be monitored and managed in hemodynamically unstable post-cardiac arrest patients?
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Study Notes
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Shoulder dystocia: a birth complication where the baby's shoulders cannot pass beyond the mother's pubic symphysis, causing the head to deliver but retract back into the perineum.
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"Turtle sign": a term used to describe shoulder dystocia where the baby's head delivers but the body does not.
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Management of shoulder dystocia:
- McRoberts maneuver: a technique to help deliver the baby where the buttocks are moved off the end of the bed and thighs are flexed upward, applying pressure above the pubic symphysis.
- Transport immediately: regardless of the success or failure of the delivery attempt.
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Nuchal cord: a condition where the umbilical cord is around the neck of the baby, commonly found during delivery and rarely associated with adverse outcomes.
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Management of nuchal cord:
- Attempt to slip the cord over the infant’s head.
- If unable to slip the cord, clamp and carefully cut it.
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Magnesium sulfate: a medication used to treat eclampsia and hypertension in pregnancy, but not recommended for pre-eclampsia. It can cause toxicity and result in cardiac arrest.
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Benefits of intramuscular (IM) drug administration over the subcutaneous (SQ) route: IM administration is more consistent in the prehospital setting, especially for obese patients and pediatrics. More predictable absorption in critical patients.
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Intranasal delivery of medications:
- A method that delivers medication as a fine aerosol into the nose, resulting in a broader distribution and increased bioavailability.
- Not all medications can be delivered intranasally, and medications that can include fentanyl, midazolam, naloxone, ketamine, and glucagon.
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Pharmacological interventions for pain management: most commonly used agents include narcotics, ketamine, nitrous oxide, nalbuphine, and NSAIDS.
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Monitoring and documentation before and after analgesic administration: documenting the patient's clinical status before and after analgesic administration is required, including vital signs, any significant changes, and corrective actions taken.
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Quality improvement and medical oversight: systems with established quality improvement programs have better compliance to pain management protocols.
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Acute vs. chronic pain management: perform a thorough pain assessment prior to providing treatment, pain management should depend on objective clinical decision making, and pain is individualized with each patient.
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Sedation monitoring: use of analgesia and sedation in the out-of-hospital setting, including the use of NSAIDs, acetaminophen, fentanyl, midazolam, and ketamine.
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Pediatric pain management: optimizing the environment, assessing pain, using non-invasive methods, and utilizing local and regional anesthesia.
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Neonatal pain management: physiologic awareness of medication use in neonates, and non-pharmacologic pain management.
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Oxygen therapy may worsen tissue damage in Acute Coronary Syndrome (ACS) and stroke patients due to the production of "free radicals."
- Free radicals are toxic byproducts of metabolism that damage membranes and increase local tissue damage.
- Reintroducing high concentrations of oxygen to cells that have been functioning anaerobically can increase free radical production and cause membrane damage and tissue death.
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In cardiac arrest patients, Return of Spontaneous Circulation (ROSC) can be recognized by:
- A sudden increase of ETCO2 level
- The presence of a pulse after an organized rhythm is observed
- The patient breathing
- Patient movement
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Post-cardiac arrest patients require optimal ventilation and oxygenation:
- Maintain an SpO2 of greater than or equal to 94%
- Avoid excessive ventilation
- Maintain ETCO2 between 35-40mm/Hg
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Hemodynamic instability in the post-cardiac arrest patient should be monitored and managed:
- Vital signs
- Vascular access
- Cardiac hemodynamics
- Hypotension: treated with fluid bolus and vasopressors
- Arrhythmias: treated as required
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Potential causes of cardiac arrest include:
- Obtaining and interpreting a 12-lead EKG
- Considering and managing reversible causes
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Airway management during cardiac arrest includes:
- BVM (Bagu-valve mask): use 2-Rescuer technique
- Endotracheal tube (ETT) placement: compressions should not be interrupted
- Supraglottic airways: acceptable during CPR
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Capnography should be attached to airways and monitored for signs of ROSC.
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Pediatric cardiac arrest may be caused by various factors including "Hs and Ts" and other underlying conditions.
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CHF may be caused by increased peripheral vascular resistance, ventricular failure, or fluid overload.
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CHF presentation/signs/symptoms include distended neck veins, peripheral edema, and difficulty breathing.
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CHF treatment includes Continuous Positive Airway Pressure (CPAP), nitroglycerin, and other medications.
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CPAP contraindications include inability to maintain own airway, hypotension, and recent esophageal surgery.
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Nitroglycerin use includes peripheral venodilation, reduction of oxygen demand in the heart, and dilation of coronary arteries, with contraindications for hypotension and use of phosphodiesterase inhibitors in the past 24-48 hours.
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Minimal equipment required for intubation (iii) has disadvantages:
- Contraindicated for patients with a gag reflex
- Some devices not suitable for patients at risk for regurgitation (e.g., LMA™)
- Misplacement can occur without recognition
- Additional contraindications may apply per local protocol
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Endotracheal Tubes (ETT) have advantages and disadvantages:
- Keeps airway patent and protects from aspiration
- Allows suctioning of deep airway secretions and potential drug administration
- Difficult initial training, requires frequent practice, and may cause trauma to the oropharynx
- Prolonged intubation attempts may cause hypoxemia
- Adverse outcomes common for inexperienced providers and inadequate monitoring
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Suctioning the airway in newborns:
- Can cause bradycardia and should be avoided unless necessary
- Should not be done immediately after birth unless an obstruction is present or positive pressure ventilation is required
- Presence of meconium does not always indicate a need for suctioning
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End tidal CO₂ (ETCO₂) measurement:
- Utilized to measure ventilation in patients
- Measures partial pressure (mmHg) or volume (% vol) of exhaled CO₂
- Reflects changes in ventilation within 10 seconds
- Breath-to-breath measurement provides information within seconds
- Not affected by motion artifact, poor perfusion, or dysrhythmias
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Physiology of CO₂:
- Carbon dioxide can be measured in arterial blood gas, mixed venous blood gas, and exhaled CO₂
- Normal ranges for PaCO₂, PvCO₂, and ETCO₂
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Measuring ventilation in intubated patients:
- Provides information on ET tube placement, tube displacement, chest compressions, ROSC, and probability of successful resuscitation
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Measuring ventilation in non-intubated patients:
- Objectively assesses acute respiratory disorders (asthma, COPD, hypoventilation, congestive heart failure, sedation and analgesia, stroke, head injury, and perfusion status)
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Interpreting ETCO₂ and capnography waveform:
- Normal waveform consists of five phases: dead space ventilation, ascending phase, alveolar plateau, end-tidal, and descending phase
- AHA Guidelines recommend oxygen administration for patients with suspected acute coronary syndrome or stroke based on SpO₂ levels and specific conditions.
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Oxygenation of chest pain and stroke patients:
- 2 L/min via nasal cannulas for patients with dyspnea, signs and symptoms of shock, or heart failure, or an SpO₂ of less than 94% on room air
- Titrate oxygen to maintain an SpO₂ of at least 94%
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