cardiac arrest and trauma Flashcards
(36 cards)
goal TTM and why
the goal is normothermia (36C)
- source: Nielsen TTM trial
no clear benefit to hypothermia (33C) in comparison
hypothermia
- is more hemodynamically unstable (can induce bradycardia - dangerous if there’s underlying torsades)
- can induce dangerous electrolyte shifts
- suppresses immune fx (a/w increased rates of PNA)
- delays accurate neuroprognostication
- keeps us from focusing on why the pt arrested (THE MOST IMPORTANT QUESTION)
Who needs TTM?
reliable hx that indicates no anoxia (i.e. witnessed arrest, immediate CPR, ROSC < 5m)?
- if yes, no TTM
following verbal commands post-arrest?
- if yes, no TTM
if no to both, perform TTM
- basically, any unresponsive post-ROSC pt w/anoxic injury
how to induce TTM36
external cooling device + anti-shivering package: scheduled APAP (1000q6), hydrocortisone (50q6), buspirone (30q8), and mag repletions
post-arrest interventions: imaging, procedures, neuro, cards, resp, renal, GI, ID
imaging: RUSH, panCT
procedures: central line, a line, Foley
- neuro: TTM36, vEEG, anti-shivering package
- cards: EKG, cards cs for cath or antiarrhythmic recs if possible cardiac cause, MAP > 75 w/pressors PRN
- resp: TV 6-8 mL/kg, normoxia, normocarbia
- renal: repletions
- GI: ppx
- endo: hydrocortisone, normoglycemia
- ID: abx (post-arrest SIRS ~ septic shock)
post-arrest vitals targets
- MAP > 75 to optimize the anoxic brain’s perfusion
- normocapnia: get the ETCO2 30-35, then get an ABG
- normoxia: 92-96%
early-onset myoclonic status: definition and significance
myoclonic jerks that happen w/n 24h of arrest and last > 30m, w/burst suppression on EEG = a bad sign
post-arrest sedation
propofol w/pressors PRN (lets you get a neuro exam, decreases shivering)
- avoid Fentanyl and benzos
arrest: immediate actions
- compressions
- access (IV/IO)
- LMA BVMs
- monitor and pads > ID rhythm
VF/pulseless VT actions (rounds 1-3)
- shock 200J, compressions x 2m > epi if no ROSC
- amio 300 > 150 or lido 100 > 50 q5-10m + 2g mag > repeat
- esmolol
asystole/PEA actions
- epi q3-5m
- cardiac/lung US
- ID rhythm and calcium if wide
- consider: LR/blood, tox
3 major causes of PEA and what to do
3 & 3 rule:
- hypovolemia
- obstruction: PTX, tamponade, massive PE
- pump failure (MI w/myocardial rupture)
3 causes of wide-complex PEA
hyperK, TCA tox, MI w/pump failure
definition of refractory VF
after 3 shocks, 3 epis, amio, lido
don’t use this in resistant VF, i.e. if they shock, come back, go out, etc.
refractory VF: how to do dual sequential defib
while compressions are ongoing, place second set of pads and shock together @200J > 1, 2, 3, shock
don’t let any of the pads touch or you’ll destroy the machines
refractory VF: how to give esmolol for “electrical storm”
50 mg bolus (“normal bolus dose”), repeat x1 –> if it helps, 50 mcg/kg/min gtt
medication to avoid in refractory VF
epi - do not contribute to the catecholamine surge
how to give lytics
weight-based tenecteplase (max 50 mg if > 90 kg)
resistant VF: strategy
start w/esmolol sooner and consider cath lab/weight-based tenecteplase (max 50 mg if > 90 kg)
- delayed cath if ST elevations are improving, cath now if they’re persistent
massive PE tx
3 arms: lytics decision, maintain perfusion, maintain oxygenation
- lytics: if absolute contraindication, IR/surgical thrombectomy; if relative contraindication, 50 mg alteplase; if no contraindication, 100 mg alteplase
- perfusion: norepi > inhaled NO if that fails
- oxygenation: if hypoxic/dyspneic, HFNC; AVOID INTUBATION
approach to the bradycardic neonate
30 sec BVM > if ineffective,
- pulse ox on R hand/wrist (preductal)
- HR monitoring w/3-lead EKG
- MR SOPA
M - mask adjustment R - reposition airway S - suction nares O - open mouth (jaw thrust, OPA, NPA, shoulder roll) P - PEEP to 5-8 and PPV >20 (max 40) A - advanced airway (LMA, then ETT)
goals of neonatal resus
warm, pink, and sweet
neonatal temperature management
avoid hypothermia at all costs
- > 32 wga w/good tone/respiration: towel, mom’s chest
- younger, poor tone/respiration: infant warmer at 25C, wet infant in plastic bag up to neck, warm blankets
goal temp = 36.5-37.5
neonatal stimulation
rubbing the back
flicking the soles
toweling the well >32 wga infant
How long does it take a neonate to achieve a normal O2 sat?
can be up to 10m
