Resuscitation Flashcards
(47 cards)
Name one trial evaluating endotracheal intubation vs. supraglottic airway device in patients. in cardiac arrest? Summarise findings
AIRWAYS-2 – RCT
* Multi-centre, cluster RCT, 9269 patients (but not all got SGA or ETT)
* SGA (supraglottic airway) associated with higher success initial ventilation
* SGA and ETT had similar rate of favourable neurological outcome (mRS 0-3) at 30 days
* No advanced airway better outcome than SGA or ETT (may be confounded by close to ED)
Causes of post-arrest hypotension
- Cardiogenic (can have element in post-arrest state)
- Hypovolaemia / Haemorrhage
- Obstructive shock: Tamponade / Pneumothorax (2o to CPR)
- SIRS response / distributive / anaphylaxis
Priorities of post-cardiac arrest care
Post resuscitations care
- Re-evaluate ABCDE
- 12-lead ECG
- Treat precipitating causes
- Aim for: SpO2 94-98%, normocapnoea and normoglycaemia
Clinical goals:
- Preventing further arrest
- Defining the underlying pathology
- Limit organ damage
- Predict non-survivors
ARC Pre-hospital Choking Algorithm
Uses for POCUS in the assessment of an adult patient in cardiac
arrest
- CARDIAC - Cardiac Output, and Cardiac Standstill
- CARDIAC - Tamponade
- LUNGS - Tension Pneumothorax
- ABDOMEN - Free Fluid in Abdomen - trauma and AAA
- CHEST - Aortic Dissection
- CARDIAC/LUNGS - DVT, PE
Mechanical CPR device: advantages and disadvantages
Advantages:
- Decreases staff utilisation
- Minimises interruptions to CPR (once attached)
- Effective and consistent chest compression
- Portability during patient transfers
Disadvantages:
- No mortality benefit
- De-skills providers
- Focuses on device attachment rather than effective CPR and early defibrillation
- Device displacement during compressions
- Blunt chest and abdominal trauma
- Device malfunction
ANZCOR recommendation regarding use of a mechanical CPR device
Does not suggest routine use
- Suggest that automated mechanical CPR devices are reasonable alternatives where
sustained high quality CPR are impractical or compromise provider safety.
Uses of waveform capnography in the resuscitation of a cardiac arrest resuscitation
- Adjunct for prognostication (Failure to achieve CO2 > 10 mmHg in 20 min is associated with
poor outcomes) - Identifies ROSC (by an increase in CO2 value)
- Confirms tracheal position and displacement
- Assess the quality of chest compressions
- Ventilation rate monitoring
Initial management and assessment of a newborn
- Clamp umbilicus
- Prevent heat loss, keep baby warm, warm towel dry under heat source
- Gentle stimulation (rubbing back, flicking soles of the feet)
- Assess APGAR score (initial cry, respiratory effort, heart rate, colour and tone)
- Ensure open airway
Newborn CPR parameters and indications
Initial face-mask (PPV) ventilation (Neopuff) at 40-60 brpm
If absent pulse, or HR <60 bpm (auscultation or palpated umbilicus) after 30 secs commence CPR
3:1 compressions-to-ventilation at 100 compressions/min
1/3rd chest depth, encircling technique
Cease when HR >60
Paediatric ALS timing and dosing
Reversible causes of cardiac arrest (adult + paediatric) - 4 H’s + 4 T’s
Hypoxia
Hypo/hyperthermia
Hypovolaemia
Hyper/hypokalaemia
Toxins
Thrombosis
Tension PTX
Tamponade
Focussed examination in decreased GCS
- Pupils – looking for toxidromes, or blown pupil of raised ICP
- Focal neuro signs c/w intracranial event
- Muscle compartments – exclude compartment syndrome due to lying on floor
- Skin examination for pressure areas
- Chest / lungs for aspiration from reduced LOC
Treatment of non-arrest hyperkalaemia
Resuscitation in rhabdomyolysis
IV fluid N/S – titrate to UO 1ml/kg/hr to manage rhabdo and prevent further renal failure
Risk of HyperK+, if present:
- IV Ca gluconate 10mL 10% (up to 60mL) for cardiac protection OR CaCl 5mL 10% (up to 30mL)
- IV HCO3 50-100mmol – K reduction
- IV insulin 10U / dextrose 50mL 50%
– Optional salbutamol for K reduction
Advantages and disadvantages of parental presence during paediatric resuscitation
Advantages:
- Allows parent to see all treatment being provided
- In case of unsuccessful resuscitation, allows initiation of grieving process
Disadvantages:
- Can worsen staff grief around events of highly emotive resuscitation
- Potential for interference with resuscitation from parents unless dedicated staff member caring for
parent
Hyperkalaemic arrest management
Protect the heart: give 10 mL calcium chloride 10% IV by rapid bolus injection or 30ml of
calcium gluconate
Shift potassium into cells: Give glucose/insulin: 10 units short-acting insulin and 25 g
glucose (50mL of 50%) IV over 15-30 mins. Monitor blood glucose.
Consider nebulised salbutamol 10-20mg
Give sodium bicarbonate: 50-100 mmol IV by rapid injection (if severe acidosis or renal
failure).
Remove potassium from body: Consider dialysis for hyperkalaemic cardiac arrest resistant
to medical treatment. Several dialysis modalities have been used safely and effectively in
cardiac arrest, but this may only be available in specialist centres.
Consider use of a
mechanical chest compression device if prolonged CPR is needed.
ERC guidelines
Medication treatment in premature labour
Betamethasone 11.4mg IM
Salbutamol 5mg neb
Tocolytics - If >32/40: Nifedipine 20mg orally, up to 3 doses Q 30min then TDS *Do not use with IV salbutamol, MgSO4, GTN, antihypertensives
- If <32/40: NSAIDs e.g indomethacin 50-100mg rectal/PO stat
Mg sulphate 2mg (up to 6mg) IV (do not use with nifedipine)
Indications for neonatal resuscitation
Poor tone
Lack of response to stimulation
HR < 100/min
Respiratory distress or lack of spontaneous respirations
Adrenaline in neonatal resuscitation
If HR <60/min after 60 seconds of chest compressions and 90 seconds of PPV
IV dose 0.1-0.3 mL/kg (10-30 µg/kg) 1:10,000
-0.25mL for < 30 weeks gestation
-0.5mL for 30-35 weeks
-1mL for > 35 weeks
ETT 0.5-1.0ml/kg (50-100 µg/kg) 1:10,000
- 1mL for < 30 weeks gestation
- 2mL for 30-35 weeks
- 3mL for > 35 weeks
Repeat every 2 mins, as required
Neonatal therapeutic hypothermia - parameters
Use in hypoxic ischaemic encephalopathy (HIE) - cooling may reduce the degree of brain injury. Commence within 6hrs after birth
Aim 33-34 degC for 72hrs from initiation and then rewarm gradually over 12-14 hours
Neonatal therapeutic hypothermia - indications/criteria
1) ≥ 35 weeks gestational age and more than 1.8kgs.
2) < 6hrs post birth
3) Evidence of asphyxia as defined by the presence of at least two of the following four criteria:
- Apgar ≤5 at 10 minutes or continued need for resuscitation with positive pressure ventilation +/- chest compressions at 10 minutes of age
- Any acute perinatal event that may result in HIE (i.e. abruption placenta, cord prolapse, severe foetal heart rate abnormality.).
- Cord pH <7.0 or base deficit of 12 or more within 60 minutes of birth
- If cord pH is not available, arterial pH <7.0 or BE>12 mmol/L within 60 minutes of birth (if available).
4) Not moribund and plans for full care
5) Clinically defined moderate or severe HIE (stage 2 or 3 based on modified Sarnat Classification)
6) Moderate to severely abnormal background activity on amplitude-integrated EEG (.i.e. discontinuous, burst suppression or low voltage +/-
7) At the neonatal consultant’s discretion to commence therapeutic cooling
Features predictive of survival in OOHCA
Witnessed arrest
Bystander CPR
Shockable rhythm (VF/VT)
ROSC in the field
Mild therapeutic hypothermia
PCI if STEMI present
Criteria for termination of resuscitation (TOR) in OOHCA
A general approach is to stop CPR after 20 minutes if there is no ROSC or viable cardiac rhythm re-established, and no reversible factors present that would potentially alter outcome.
From past Q:
No Shock has been administered *
No bystander CPR performed *
No ROSC has occurred
The OHCA was not witnessed by EMS
The OHCA was not witnessed by bystanders
