Chapter 12: Resuscitation in Special Circumstances Flashcards
(137 cards)
1
Q
What happens to potassium in acidosis?
A
- Serum K+ increase as it moves from cells to serum
- H+/K+ pump
2
Q
How is hyperkalaemia defined and what classifies as severe?
A
K+>5.5 mmol/L
Severe >6.5 mmol/L
3
Q
What can cause hyperkalaemia?
A
- Renal failure
- Acidosis
- DKA
- Drugs - Spironolactone, ACEi, amiloride, ARB, NSAID’s, B blockers, trimethoprim
- Endocrine - Addison’s disease
- Tissue breakdown - rhabdomyolysis, TLS, haemolysis
4
Q
How may hyperkalaemia present?
A
Arrhythmia
Weakness - flaccid paralysis, paraesthesia, depressed tendon reflexes
5
Q
What ECG changes do you see with hyperkalaemia?
A
- Absent/small p waves
- Prolonged PR
- Wide QRS
- Can see ST segment depression
- S and T merging
- Tall tented T waves
- VT
- Bradycardia
- Cardiac arrest
6
Q
How is hyperkalaemia treated?
A
- STOP DRUGS/K+ fluids
- IV Calcium chloride - 10ml/10% over 2-5 mins
- Insulin/Dextrose - 10 units in 250ml of 10% 15-30min
- Sodium bicarbonate - 50mmol IV bolus - severe acidosis or renal failure
- Salbutamol nebulised 10-20mg
- Dialysis
- K+ binder - calcium resonium 15-30g or Sodium Polystyrene Sulfonate
7
Q
What do you do for each stage of hyperkalaemia?
A
Mild: 5.5-5.9
1. Address cause
2. Calcium resonium or sodium polystyrene sulfonate
Mod: 6.0-6.4
1. Insulin dextrose
2. As above
Severe: 6.5+
1. Expert help
2. Calcium chloride
3. Shifting agents
4. Remove K+ - dialysis
8
Q
What are the main risks associated with hyperkalaemia treatment?
A
- Hypoglycaemia - monitor BM
- Tissue necrosis - secondary to extravasation of intravenous calcium salts - Ensure secure vascular access
- Intestinal necrosis and obstruction - K+ exchange resin - avoid prolonged use and give laxative
- Rebound hyperkalaemia - after drug treatment warn off - monitor for at least 24hr
9
Q
What is important to know about cardiac arrest in haemodialysis patients?
A
- Sudden cardiac death most common cause
- Usually ventricular arrhythmia
- Stop ultrafiltration, give fluid and return pt blood volume
- Disconnect dialysis machine
- Use dialysis access for drugs
- Early defib
10
Q
How is hypokalaemia defined?
A
- < 3.5mmol/L
- Severe = < 2.5mmol/L
11
Q
What can cause hypokalaemia?
A
- GI losses
- Alkalosis
- Drugs - loop diuretics, thiazides, laxatives, steroids
- Renal losses
- Cushings/hyperaldosteronism
- Mg depletion
- Poor intake
- Overtreated High K+
12
Q
How can you recognise hypokalaemia?
A
- R/O in all arrhythmia/cardiac arrest
- Seen at end of haemodialysis or in peritoneal dialysis
- Symptoms: Fatigue / Weakness / Leg cramps / Constipation
- If severe: Rhabdomyolysis / Ascending paralysis / Resp difficulties
13
Q
What ECG features are seen in hypokalaemia?
A
- ST segment changes
- Small T waves
- U waves
- Arrhythmia
- Cardiac arrest
14
Q
How should K+ be replaced?
A
- Gradually
- Max 20mmol/L per hour
- More rapid infusion indicated in unstable arrhythmia - 2mmol/L/min for 10 mins then 10mmol over 5-10 mins
15
Q
What can cause hypercalcaemia?
A
- Primary/tertiary hyperparathyroidism
- Malignancy
- Sarcoid
- Drugs
16
Q
How does hypercalcaemia present?
A
- Abdo pain
- Hypotension
- Weakness
- Confusion
- Arrhythmia
- Cardiac arrest
17
Q
What ECG changes are seen in hypercalcaemia?
A
- Short QT
- Wide QRS
- Flat T waves
- AV block
- Cardiac arrest
18
Q
How is hypercalcaemia treated?
A
- Fluid replacement
- Furosemide - 1mg/kg
- Hydrocortisone 200-300mg
- Pamidronate 30-90mg
- Rx underlying cause
19
Q
What can cause hypocalcaemia?
A
- Chronic renal failure
- Pancreatitis
- CCB OD
- Toxic shock syndrome
- Rhabdomyolysis
- TLS
20
Q
How does hypocalcaemia present?
A
- Paraesthesia
- Tetany
- Seizures
- AV block
- Cardiac arrest
21
Q
What ECG changes are seen for hypocalcaemia?
A
- Prolonged QT
- T wave inversion
- Heart block
- Cardiac arrest
22
Q
What can cause hypermagnasaemia?
A
- Renal failure
- Iatrogenic
23
Q
How does hypermagnasaemia present?
A
- Confusion
- Weakness
- Resp. depression
- AV block
- Cardiac arrest
24
Q
What ECG changes are seen for hypermagnasaemia?
A
- Prolong PR
- Prolonged QT
- T wave peak
- AV block
- Cardiac arrest
25
How is hypermagnasaemia managed?
1. **Calcium chloride 10ml 10%**
2. **Saline diuresis** - furosemide 1mg/kg + 0.9% saline
3. **Ventilatory** support if req.
4. **Haemodialysis**
26
What can cause hypomagnasaemia?
1. **GI loss**
2. **Malabsorption**
3. **Starvation**
4. **Alcohol**
5. **Polyuria**
27
How does hypomagnasaemia present?
1. **Tremor**
2. **Ataxia**
3. **Nystagmus**
4. **Seizures**
5. **Arrhythmia** - torsades
6. Cardiac **arrest**
28
How does hypomagnasaemia present on ECG?
1. **Flat p waves**
2. **Prolong PR** and **QT**
3. **Wide QRS**
4. **ST depression**
5. **T wave inversion**
6. Can get **polymorphic VT - torsades**
29
How is hypomagnasaemia managed?
1. **2g 50% MgSo4** (4ml 8mmol/L)
- **severe** = over **15 mins**
- **torsades** = over **1/2 mins**
- **Seizure** = over **10 mins**
30
How is septic shock defined?
1. **Lactate > 4mmol/L**
2. **Hypotension** **unresponsive** to **fluid** resus
## Footnote
50% mortality
31
What are the common causes for mortality in poisoning?
1. **Airway obstruction** and **respiratory arrest** secondary to decreased conscious level - early tracheal intubation
2. Drug induced **hypotension** - usually respond to IV fluids but may need vasopressor support
## Footnote
Electrolytes, BM and ABG's should be checked as they commonly cause mortality
32
What modifications are required to resus in poisoning?
1. **Avoid mouth to mouth** breathing in presence of cyanide, hyrogen sulphide, corrosives and organophosphates
2. Check for **hypo/hyperthermia**
3. Focus on **correcting hypoxia, hypotension**, **acid/base** and **electrolytes**
4. Be prepared for **long resus time** and consider ECLS
5. **Seek** expert **advise** and consult **TOXBASE**
33
What specific treatments are available for poisoning?
1. **Removal of clothes** - skin exposure
2. Gastric **lavage** and **laxatives** **NOT used**
3. **Activated charcoal** - **< 1hr** and **intact airway**
4. **Whole bowel irrigation** using **polyethylene glycol**
5. **Sodium Bicarb** IV
6. **Haemodialysis**
7. **Specific antidotes**
## Footnote
Activated Charcoal (QuiT CPD) - **carbamazepine**, **dapsone**, **phenobarbital**, **quinine** and **theophylline**
Polyethylene glycol - sustained release/enteric coated **drugs**, oral **iron** poisoning, removal of ingested packets **illicit drugs**
Soda Bic - **salicylate** poisoning
Haemodialysis - Drugs with **LMW**, **low protein binding**, **small VoD**, **high H2O solubility**
34
What is the specific antidote for paracetamol?
1.**N-acetylcysteine**
35
What is the specific antidote for organophosphate poisoning?
1. High dose **atropine**
36
What is the antidote for cyanide poisoning?
1. **Hydroxocobalamin**
2. 50% mortality **thiosulphate**
3. **Sodium nitrite**
4. **Amyl nitrite**
37
What is the antidote for digoxin poisoning?
1. **Digibind** - digoxin specific Fab **antibodies**
38
What is the antidote for benzodiazepines?
1. **Flumazenil** if no risk of seizure
39
What is the antidote for opioid poisoning?
1. **Naloxone 400mcg** IV, **800mcg IM**, **800mcg SC** or 2mg Intranasal
2.Non IV may be quicker - save time getting access
3. **Duration of action not as long as respiratory depression persist**- **give increments** until breathing adequately
40
What does opioid poisoning cause?
1. **Pinpoint** pupils
2. **Resp depression**
3. **Resp. arrest** - **Coma**
41
What happens if opioids are withdrawn acutely in poisoning?
State of **sympathetic excess** leading to complications:
1. Severe **agitation**
2. **Pulmonary oedema**
3. Ventricular **arrhythmia**
## Footnote
**Use naloxone cautiously** in patients with dependence
42
What can a benzodiazepine OD cause?
1. **LOC**
2. **Resp depression**
3. **Hypotension**
43
What can reversal of benzodiazepine OD with flumazenil lead to in patients with dependence or have coinjested pro-convulsants?
1. **Withdrawal** syndrome
2. **Seizure**
3. **Hypotension**
4. **Arrhythmia**
44
Is flumazenil used in comatose patients?
**No**
45
What can tricyclic antidepressant OD cause?
1. **Anti-cholinergic** effects - mydriasis, fever, dry skin, delirium, tachycardia, ileus, retention
2. Life-threatening **arrhythmia** - commonly shockable
3. **Hypotension**
4. **Seizure**
5. **Coma**
46
What may indicate that a TCA overdose will lead to arrhythmia?
1. **Wide QRS**
2. **Right axis deviation**
## Footnote
Rx - Consider **sodium bicarb**
47
When can you get local anaesthetic toxicity?
1. **Regional anaesthesia** - enters artery or vein
48
What issues can you get with local anaesthetic toxicity?
1. Severe **agitation**
2. **LOC**
3. With or without tonic-clonic **convulsions**
4. Sinus **Bradycardia**/ Conduction **blocks**/**Asystole**/**VT**
49
How can local anaesthetic toxicity be treated?
1. **Resus** measures
2. IV **20% lipid emulsion**
3. Initial **1.5mL/kg bolus** in 1 min
4. Give up to **3 boluses** at 5 min intervals
5. Followed by **15mL/kg/hr infusion**
6. **Max 12mL/kg** emulsion
50
What should you do following lipid emulsion rescue for local anaesthetic toxicity?
1. **Exclude Pancreatitis** - daily amylase or lipase assays for 2 days
2. Safe. **transfer** to clinical area
3. Report cases to **National Patient Safety Agency**
51
What can cocaine toxicity cause?
**Sympathetic** overstimulation:
1. **Agitation**
2. **Hyperthermia**
3. Symptomatic **tachycardia**
4. **Hypertensive** crisis
5. Myocardial ischaemia with **angina**
52
What can be done to treat cocaine toxicity?
1. Small dose **IV benzo** (midazolam, diazepam, lorazepam)
2. **GTN** and **phentolamine** - reverse coronary vasoconstriction
3. Can consider **beta blockers** and **anti-arrhythmics** - best unclear
4. If **arrest** - use **normal adreanline dose**
53
How is drug induced severe bradycardia managed?
1. **Atropine** - organophosphate, carbamate, nerve agent poisoning or acetylcholinesterase inhibitors
2. **2-4 mg IV** repeated doses
54
What can be used to treat bradycardia due to beta blockers or calcium channel blockers?
1. Can use **Isoprenaline** at high dose if refractory bradycardia due to beta blockers
2. **Inotropes**
3. **Vasopressors**
4. **Calcium**
5. **Glucagon**
6. **Phosphodiesterase inhibitors**
7. High dose **insulin-dextrose-potassium infusions**
55
Which asthmatic patients are at highest risk for near fatal attacks?
1. Prev Hx of **intubation** and mechanical **ventilation**
2. **Hospitalisation**/emergency care **in last year**
3. **Low** or no use of **inhaled ICS**
4. Increased use/**dependence** on **SABA**
5. **Anxiety**, **depression** and/or poor compliance
6. **Food allergy**
56
What can cause cardiorespiratory arrest in asthmatic patients?
1. **Severe bronchospasm** and **mucous plugging** - **asphyxia**
2. **Hypoxia** - cardiac **arrhythmia**
3. **Dynamic hyperinflation** in mechanically ventilated - **reduced venous return** and BP
4. Tension **pneumothorax**
## Footnote
Arrhythmia - Can also be due to drugs or electrolyte abnormalities
57
What signs indicate acute severe asthma?
1. PEFR **33-50%**
2. **RR >25**
3. **HR >110**
4. **Inability** to **complete sentence in 1 breath**
58
What signs indicate life-threatening asthma?
1. **Altered conscious** level
2. **Exhaustion**
3. **Arrhythmia**
4. **Hypotension**
5. **Cyanosis**
6. **Silent chest**
7. **Poor resp** effort
8. **PEFR < 33**
9. **SpO2 < 92%**
10. **PaO2 < 8kPa**
11. **'Normal' PaCO2 - 4.6-6**
59
What indicates asthma may be near fatal?
1. **Raised PaCO2**
2. And/or mechanical ventilation with **raised inflation pressures**
60
What may absence of wheezing in asthma indicate?
1. **Critical** airway **obstruction**
## Footnote
Increased wheezing may indicate **+ response to therapy**
61
What can happen to SpO2 in SABA therapy of asthma?
1. May **initially decrease**
2. Beta agonists cause **bronchodilation** and **vasodilation**
3. D/t - **increased intra pulmonary shunting**
62
How can acute asthma attacks be managed?
1. **High flow O2** - sats of 94-98%
2. **Salbutamol 5mg neb** - repeat every **15-30 mins** or cont. 5-10mg/hr
3. Add **neb ipratropium bromide** **500mcg 4-6hr**
4. **Prednisolone 40-50mg** PO or hydrocortisone 100mg IV
5. Can give IV **Magnesium sulphate 2g** (8mmol) over 20 mins
6. Consider **IV salbutamol 250mcg** if inhaled not possible
## Footnote
Senior advice for **aminophylline** - 5mg/hr IV 20 min then 500-700mcg/kg/hr infusion (max dose 20mcg/mL to avoid toxicity)
63
What can beta agonist and steroid therapy in asthma cause?
1. **Hypokalaemia** - correct
64
When should tracheal intubation and controlled ventilation be considered in asthma?
1. **Reducing** peak flow
2. **Reduced consciousness**
3. Persisting/**worsening hypoxaemia**
4. **Worsening** resp. **acidosis**
5. **Worsening agitation** & confusion - fighting against O2 mask
6. Worsening **exhaustion**
7. Cardioresp. **arrest**
## Footnote
Role of non invasive ventilation unclear - only considered in ICU setting
65
How is ALS modified in acute asthma?
1. **Intubate early** - high risk of GI inflation and hypoventilation if ventilate without tracheal tube
2. **RR 10 breaths**
3. **Normal** tidal **volume**
4. If **dynamic hyperinflation** - **compress chest wall** + disconnect tracheal tube
5. Be aware of **tension pneumothorax**
6. Consider **extracorporeal** life support
66
Which 3 criteria are indicative of anaphylaxis?
1. **Sudden onset** and **rapid progression** of symptoms
2. **Life threatening airway** and/or **breathing** and/or **circulatory** problems
3. **Skin** and/or **mucosal changes** - flushing, urticaria, angioedema
67
What is important to remember about recognising anaphylaxis?
1. **Skin** and mucosal changes **alone not a sign**
2. **Skin** and mucosal changes can be subtle/**absent**
3. Can be **GI symptoms**
68
How is anaphylaxis managed in an adult?
1. **Remove trigger**
2. **Lie down**
3. **IM Adrenaline 0.5mg** (0.5ml of 1:1000) - anterolateral middle thigh
4. IV **Fluid** challenge 500-1000ml
5. IV **chlorphenamine 10mg**
6. IV **hydrocortisone 200mg**
69
How is anaphylaxis managed in children?
**Fluids**:
1. **Crystalloid 20ml/kg**
Child **6-12**:
1. IM **adrenaline 0.3mg**
2. IV **chlorphenamine 5mg**
3. IV **hydrocortisone 100mg**
Child **6 month to 6 yo**:
1. IM **adrenaline 0.15mg**
2. IV **chlorphenamine 2.5mg**
3. IV **hydrocortisone 50mg**
Child **< 6 months**:
1. IM **adrenaline 0.15mg**
2. IV **chlorphenamine - 250mcg/kg**
3. IV **hydrocortisone 25mg**
70
When can IV adrenaline be used in anaphylaxis?
1. Only by **specialists**
2. May be used **if repeated IM doses**
## Footnote
**Max 50mcg in adults**
**1mcg/kg** in **children**
Can cause **hypertension**, tachycardia, **ischaemia**, arrhythmia if spontaneous circulation
71
How can anaphylaxis be investigated?
**Mast cell tryptase** - 3 timed samples:
1. **ASAP** after resus
2. **1-2hr after** start of symptoms
3. **24hr after**
72
What can cause cardiac arrest in pregnancy?
1. **Haemorrhage**
2. **Ectopic**
3. **Cardiac** disease
4. **Hypertensive** disease - eclampsia/pre-eclampsia
5. **PE**
6. **Amniotic** fluid **embolus**
7. **Sepsis**
8. **Psychiatric** disorders
73
How do you initially treat a distressed/compromised pregnant patient?
1. **Left lateral position**/manually displace uterus - relieve pressure on IVC
2. **High flow O2**
3. **Fluid** bolus
74
How is cardiac arrest management modified in pregnancy?
1. Summon **help immediately**
2. Start **CPR** - **hand** may be **slightly higher**
3. Establish **IV access above diaphragm**
4. **Manually displace uterus**/left lateral tilt 15-30 degrees
5. Prep for **C/S**
6. **Early** tracheal **intubation**
7. May need **alternative pad positions** for defibrillation
75
How is haemorrhage in pregnancy managed in cardiac arrest?
1. **Fluid** Resus
2. **Tranexamic acid** and correct coagulopathies
3. **Rx uterine atony** - Oxytocin, ergometrine, prostaglandins and uterine massage
4. **Uterine** compression **sutures**, **packs** or intrauterine balloon **devices**
5. **Surgical control** - aortic cross clamp/compression and hysterectomy.
## Footnote
Placenta percreta may req. intra-pelvic surgery
76
How is pre-eclampsia treated?
1. **Magnesium sulphate** - prevent eclampsia in labour
77
How are amniotic fluid emboli managed?
1. **Supportive**
2. **Correct coagulopathies**
78
Should fibrinolysis be given in PE in pregnancy?
1. Must be **carefully considered**
2. **Yes** If - **Dx suspected** and maternal **cardiac output CANNOT** be **restored**
79
When is peri-mortem C-section considered?
1. **< 20 wks - not** considered
2. **20-23 wks** - Initiate emergency delivery to permit successful **resus of mother** **not** for survival of **infant**
3. **> 24 wks** - initiate for **both mother and infant**
80
What is important in post resus care for pregnant patients?
1. Targeted **temperature management**
2. **Fetal heart monitoring**
2. **ICD's** can be used
81
What are the key causes of cardiac arrest in trauma patients?
1. **Severe TBI**
2. **Hypovolaemia**
3. **Hypoxia**
4. Tension **pneumothorax**
5. Cardiac **tamponade**
6. **Direct injury** to vital organs
82
What is commotio cordis?
1. Actual or near **arrest** caused by **blunt impact to chest** wall **over** the **heart**
2. If **coincide** with **T wave** - can lead to **VF**
83
What factors are associated with survival from traumatic cardiac arrest?
1. **Pre-hospital time**
2. **Duration** of **CPR** < 20 min
3. Presence of **reactive pupils**
4. **Organised ECG** rhythm
5. **Respiratory activity**
## Footnote
Prolonged CPR - poor outcome (stop. after 20 mins if no response)
84
What is a key focus of traumatic cardiac arrest management? What may be helpful to use in these cases?
1. **Correct** the **reversible** causes
2. **Do chest compressions** but unlikely to be successful without correction
3. **FAST scan** or CT may be useful in guiding treatment
4. **Early tracheal intubation** can be beneficial
85
What can happen if positive pressure ventilation is used in low cardiac output conditions?
1. Further **circulatory depression**
2. By **impeding venous return**
86
How are tension pneumathoraces managed in traumatic cardiac arrest?
Bilateral thoracotomies:
1. **5th ICS, MAL**
2. Can extend to **clamshell** thoracotomy if req
3. **Needle decompression** is a v **temporary** measure
87
How is a cardiac tamponade managed?
1. Resuscitative **clamshell thoracotomy**
2. **Needle aspiration unreliable** - pericardium commonly full of clotted blood
88
When should resuscitative thoracotomies be considered?
1. **Penetrating torso trauma** and **< 15min CPR**
2. **Blunt trauma** and **< 10min prehospital CPR**
3. **No pulse after penetrating chest** or cardiac injuries and **signs of life** or ECG activity
89
What are the commonest causes of anaesthesia related cardiac arrest?
1. **Airway** management
90
What are the most common rhythms seen in peri op cardiac arrest?
1. **Asystole - 41%**
| VF - 35%
91
What is important about the management of periop cardiac arrest?
1. Use **fluid warmers** and **forced air warmers**
2. PEA may not be immediately detected - **use low end tidal CO2** to provoke **pulse check**
3. **CPR** is ideal in **supine position** but possible prone
4. Consider **open cardiac compressions** if heart easily accessed
5. Give **pre-cordial thump** if no immediate access to defib
6. **Stop surgery** in **asystole** or **extreme Brady** - likely excess vagal activity - **Atropine 0.5mg**
7. If **adrenaline** - give dose in **50-100mcg increments** instead of 1mg bolus. No response - further **1mg boluses**
92
What is key to know about cardiac arrest following cardiac surgery?
1. Relatively **common**
2. Recognition of need to perform **re-steronomy early is key** - tamponade or haemorrhage
3. **External compressions** may cause sternal disruption and **cardiac damage**
4. Use **Adrenaline cautiously** and **titrate** to effect IV upto **0.1mg**
93
When is emergency resternotomy indicated?
1. **Adequate airway** and ventilation
2. **3 shock attempts** in VF/pVT
3. **Asystole/PEA**
## Footnote
Do resternotomy without delay. Ideally within 5 mins of arrest
94
Should you do external chest compressions in cardiac arrest following cardiac surgery?
1. **Yes** - start **immediately if no output**
2. **Check effectiveness** using **arterial trace** - systolic of >60 and diastolic >25; HR 100-120
3. If **not** reaching targets - **resternotomy**
95
What is drowning and what are the "types"?
1. **Respiratory impairment** from **submersion/immersion** in **liquid**
2. **Submersion** - **face underwater**/covered by water
3. **Immersion** - **head** remain **above** water - e.g. life jacket
96
What typically happens to patients who are immersed in water?
1. Become **hypothermic**
2. **Airway** remain **patient**
3. **Water splashes** can cause **aspiration**
97
What happens in submersion?
1. Patient initially hold breath and **swallow water**
2. As pt. become **hypoxic** and **hypercapnic**
3. **Breath holding reflex** and laryngospasm reflex **lost**
4. Patient **aspirate** water
5. **Hypoxia** - **Bradycardia** - cardiac **arrest**
## Footnote
**Laryngospasm reflex prevent water** entering **lungs**
98
How should you correct hypoxaemia following submersion?
1. **Ventilation only resus**
99
How do you attempt to rescue someone from the water?
1. **Ideally throw rope** or buoyant rescue aid
2. **Assess risk** and **enter** with **flotation device**
3. If **submersion** for **< 10 mins** - likely **good outcome**
4. If **> 25 mins** - likely **poor outcome**
5. **Remove** from water **horizontally** - spinal precautions rarely necessary
100
Why remove patients horizontally from the water?
1. **Hypovolaemia** after prolonged immersion
2. Can **cause CV collapse** and **arrest**
101
When are spinal precautions necessary in water rescue?
1. Diving in **shallow water**
2. Signs of **severe injury** water side
3. **Water skiing**
4. **Kite surfing**
5. **Watercraft** racing
## Footnote
If pulseless and apnoeic - remove asap while limiting neck movement
102
What initial rescue should you do for patients once retrieved from the water?
1. Check for **response**
2. Give **5 rescue breaths** with supplemented oxygen
3. **Start CPR** as normal
4. If lots of foam - **continue CPR** until **intubation**
5. **Turn victim** to side and **remove regurgitation** material
103
What modifications can be made to ALS after drowning?
1. **Use PEEP** and **NG stomach decompress** in drowning pt who hasn't arrested or achieved ROSC
2. Check **ECG** and **end tidal CO2** for signs of life
3. Consider **echo** (pulse not sufficient)
4. Give **rapid IV fluid** - pt. become hypovolaemic due to cessation of hydrostatic pressure from water
104
What is important about post resus care after drowning?
1. **Risk** of developing **ARDS** - use standard protective ventilation stratefies
2. **Pneumonia common** however prophylactic Abx only if sewage/grossly contaminated
3. **Neurological outcome** determined by **hypoxia**
4. Consider **ECMO** for **refractory** cardiac **arrest**, hypoxaemia and submersion in ice cold water
105
Define hypothermia
1. **< 35** degrees
2. **Mild** = **32-35**
3. **Mod** = **28-32**
4. **Severe** = **< 28**
106
What happens in each stage of hypothermia?
1. **Mild** - **shivering**, conscious
2. **Mod** - **stop shivering**, conscious
3. **Severe** - **decreased consciousness**, vitals present (28-24)
4. **Unconscious** - vitals not present **< 24**
5. **Death** - due to irreversible hypothermia **< 13.7**
107
What may increase risk of hypothermia?
1. Things that **decrease conscious level** - **drugs**, **alcohol**, illness, exhaustion, neglect
2. Factors that **impair thermoregulation** - elderly and very young
108
Where is a core body temperature taken from?
1. Lower third of **oesophagus**
109
How much does hypothermia reduce oxygen demand?
1. **6% reduction** per **1 degree**
110
Why must you be careful diagnosing death in hypothermic?
1. Patients can have slow **small volume irregular pulses** and **low BP** but they **may return once warm**
2. Not dead until **warm and dead**
3. At **18** degrees, **brain survive 10 times** as long from circulatory arrest than at 37
## Footnote
**Good survival** has been reported in arrest and **core temp of 13.7** degrees after immersion for 6.5 hours with CPR in adults
111
How should CPR be modified in hypothermic patients?
1. **< 28** - 5 min CPR, **5 min break**
2. **< 20** - 5 min CPR, **10 min break**
3. Check for **pulse for 1 minute** - central artery and ECG
4. Consider using **mechanical chest compression**
5. Early **intubation**
6. **Hold adrenaline** and **amiodarone** until **>30 degrees**
7. Then **double dose interval** (6-10 mins) until 35 degrees
112
How are arrhythmia's treated in hypothermia?
1. Apart from VF, **others revert spontaneously** as temp increase
2. Cardiac **pacing not indicated** **unless haemodynamic compromise persist** after rewarming
3. Stop shocks after 3 attempts until **temp >28-30**
## Footnote
Sinus **Brady** --> **AF** --> **VF** --> **asystole**
113
How are patients rewarmed after accidental hypothermia?
1. **Remove from cold**
2. Take **off wet clothes**
3. **Stage II and worse** - **immobilise**, handle carefully, **oxygenate**, dry and give clothes, **heat packs**
4. **Stage I** - **mobilise** as rewarm - **exercise** rewarm patient
## Footnote
Patients continue to cool after removal from cold environment - faster if stage II or worse
114
Where should hypothermic patients be taken?
1. **Stage I** - nearest **hospital**
2. **II - IV** - Nearest hospital with **ECMO facilities**
3. **V** - Consider whether to **withhold CPR**, if not nearest hospital with **ECMO**
115
What are the reasons to terminate (or not attempt) CPR in a hypothermic patient?
1. **DNACPR**
2. **Obvious** sign of **irreversible death**
3. **Unsafe** for rescuer
4. **Avalanche** burial for **>60 min**
5. **Airway packed** with **snow**
6. **Asysole**
116
When are avalanche victims not likely to survive?
1. **Buried for > 60 mins** + cardiac **arrest** + **obstructed airway** on extraction
2. **Buried** + cardiac **arrest** + **K+ >8mmol/L**
117
When can extracorporeal life support rewarming be considered?
1. **Temp < 32**
2. **K+ < 8mmol/L**
## Footnote
Veno-arterial ECMO preferred as more rapidly available, less anticoagulation, provide prolonged cardioresp support after rewarming
118
What other active rewarming techniques can be used?
1. Forced **warm air**
2. **Warm infusions**
3. Forced **peritoneal lavage**
119
What are the stages of hyperthermia?
1. Heat **stress**
2. Heat **exhaustion**
3. Heat **stroke** --> multi-organ dysfunction and cardiac arrest
120
What is heat stroke + types?
1. Core **temp >40.6**
2. **Change** in **mental** state
3. Varying levels of **organ dysfunction**
2 types:
1. **Exertional**
2. **Non exertional** - elderly in heat waves
121
What can predispose someone to heat stroke?
Elderly:
1. Underlying **illness**
2. **Medication** use
3. **Declining** thermoregulatory **mechanisms**
4. **Limited** social **support**
General:
1. **Lack** of **acclimitisation**
2. **Dehydration**
3. **Alcohol**
4. **Obesity**
5. **CVS** conditions
6. **Skin** disease
7. **Hyperthyroidism**
8. **Phaeochromocytoma**
122
What drugs can predispose to hyperthermia?
## Footnote
ABCCD - MPS
1. **Anticholinergics**
2. **Beta blockers**
3. **Ca2+ blockers**
4. **Cocaine**
5. **Diamoprhine**
6. **Methamphetamine**
7. **Phenothiazines**
8. **Sympathomimetics**
123
What are the features of heat stroke?
1. Core **Temp >40**
2. **Hot** dry skin
3. **Fatigue**, **headache**, fainting, facial flush, D&V
4. **CVS** dysfunction - **arrhythmia** and hypotension
5. **Resp** dysfunction - **ARDS**
6. **CNS** dysfunction - **seizures** and coma
7. **Metabolic** dysfunction - **Liver** and **renal** **failure**
8. **Haematological** dysfunction - **Coagulopathy**
9. **Skeletal** mm. dysfunction - **Rhabdomyolysis**
124
What differentials do you have to consider for raised core temperature?
1. **Drug withdrawal** syndromes
2. **Neuroleptic malignant** syndrome
3. **Sepsis**
4. **CNS** infection
5. Endocrine disorder - thyroid and **phaeochromocytoma**
125
How is heat stroke treated?
1. Rapid **cooling**
2. Haemodynamic monitoring - **fluid** and electrolytes
3. **Defibrillation** as normal
4. **Post resus** care as normal
126
How do you cool a patient in heat stroke?
1. **Simple** - cool **drinks**, take off clothes, **fan**, spray tepid water, **ice packs** over groin, axilla neck
2. **Advanced** - **cold IV fluids**, intravascular cooling catheters, **ECMO**
## Footnote
**Immerse** in **cold water** - can cause vasoconstriction, preventing heat dissipation
Diazepam for seizures
127
What is used in treatment of malignant hyperthermia?
**Dantrolene**
128
What factors influence severity of electrocution injury?
1. **Type** of **current** - AC/DC
2. **Voltage**
3. **Magnitude** of **energy**
4. **Resistance** to current **flow**
5. **Pathway** of current
6. **Area** and **duration** of contact
129
What reduces skin resistance to electrocution?
**Moisture**
130
What is most likely to be damaged in electrocution?
1. Conductive **neuovascular bundles**
131
What does contact with AC current lead to?
1. **Tetanic contract** of skeletal muscle
132
What can cause myocardial or respiratory failure in electrocution?
1. **Resp arrest** due to **paralysis of respiratory muscles** or resp depression
2. **Asystole** may be primary or secondary to **asphyxia** following resp arrest
3. Current can **precipitate VF** if it **crosses myocardium** during vulnerable period.
4. Current can cause **coronary artery spasm**
133
What current direction is more likely to be dangerous?
1. Current that **transverse myocardium**
2. **Transthoracic pathway** (hand to hand) **more** likely to be **fatal** than vertical (hand - foot) or straddle (foot - foot)
134
In patients who survive an initial electric shock, what may happen?
**Catecholamine release** or autonomic stimulation:
1. **Tachycardia**
2. **Hypertension**
3. **Prolonged QT** and transient t wave inversion
4. **Myocardial necrosis**
5. **CK release**
135
How are lightning strikes and electrical injuries treated?
1. **Early intubation** - airway management may be difficult if burns
2. **Ventilatory support** if muscle paralysis persist
3. Use **standard defibrillation** guidelines
4. **IV fluids** if tissue destruction - good urine output
5. **Remove smouldering clothing** and shoes to prevent thermal injury
6. **Check** for **compartment syndrome**
7. **Early surgery** if req.
136
What arrhythmia is most likely to be seen in an electrocution - AC & DC?
1. **AC** - **VF**
1. **DC** - **Asystole**
137
What determines long term prognosis for electrical injury?
1. **Severe** burns
2. **Myocardial necrosis**
3. **Extent** of **CNS** injury
4. **Multiple** system **organ** failure
