Resuscitation / Critical Illness Flashcards

Question

DROWNING Prognosis

Answer 1

**Prognosis** * no clinical score 100% accurately predicts which patients will survive the drowning event * submersion time correlates with survival in some studies - may be difficult to determine accurately - 85% of survivors with good neurological recovery are submerged \< 6 minutes - 7.5% for 6–10 minutes - 5% for 11–59 minutes - \<1% greater than 60 minutes - \> 10 minutes is considered a possible cut-off point for non-survival * efficiency of initial resuscitation influences outcome * water temperature no longer believed to influence outcome * non-reactive pupils and a GCS of 5 on arrival in ICU are the best independent predictors of a poor neurological outcome * 75% of survivors have good neurological outcome **Orlowski scale** * age \< 3 years * estimated submersion \> 5 minutes * no attempted resuscitation in the first 10 minutes after rescue * coma on arrival at the ED * metabolic acidosis on arrival with pH \< 7.10 * outcome - 90% chance of good recovery if \< 3 of the above present - 5% recovery if \> 3 present **Glasgow coma scale** * patients with decorticate / decerebrate / flaccid response at 2 - 6 hours after rescue rarely survive or survive only with significant neurological impairment * GCS of 5 = 80% risk of death / severe deficit * patients with neurological improvement within 2 - 6 hours following rescue often recover with little or no neurological deficit * 34% of comatose patients on arrival in ED die after presentation * children comatose on arrival in ED - 45% survive with normal brain function - 15% survive with incapacitating brain damage - 40% die * patients with neurological improvement within 2 - 6 hours following rescue often recover with little or no neurological deficit * time of first spontaneous respiratory effort - if \< 15 - 30 minutes after rescue, \< 10% have significant neurological deficit - if 60 - 120 minutes after rescue, 50 - 80% chance of sustaining serious neurological damage **Other prognostic factors** * on arrival in ED * good prognosis -spontaneous respiration and heart beat •poor prognosis - resuscitation duration \> 25 minutes - VT or VF on initial ECG - fixed dilated pupils - cardio or respiratory arrest **Prognosis in drowning and hypothermia** * patients with a core temperature \> 33o C who have not ingested alcohol or other drugs and who do not make any respiratory effort \< 40 minutes of rescue are unlikely to survive without significant brain damage * in a study of 98 children with open water immersion and body temperature of \< 34C, no child survived with good neurological outcome after \> 25 min. of CPR * chance of survival is related to rapidity of onset of hypothermia -the more rapidly cooled = better chance of resuscitation •water temperature rarely cold enough in Australia to provide protective effect from immersion **When CPR is likely to be futile** * water temperature \> 6C and immersion time \> 30 min * water temperature \< 6C and immersion time \> 90 min * submersion \> 10 min without hypothermia (nearly all cases in Australia) * persistent apnoea and asystole after 1 hour of post-rescue CPR provided not hypothermic * serum K+ \> 11 mmol/L * blood is frozen

Answer 2

**HISTORY:** ## Footnote **Precipitating event** * syncope * seizure * drugs / alcohol * hyperventilation * trauma **Type of immersion** * the type and temperature of the water * the amount and type of water contamination * time of submersion and removal, if known * conscious state on removal from water **Prehospital care** * bystander resuscitation / details (who administered and method of CPR) * time of EMS arrival and commencement of resuscitation * vital signs and conscious state on arrival of EMS - breathing spontaneously - palpable pulse - GCS * vomiting during rescue or resuscitation (very common) * transportation time **Past history** * epilepsy * alcohol abuse * drug ingestion **NAI** •consider non-accidental injury or neglect in children

Answer 3

**Management** **•follow standard ACLS protocols** - chest compressions are ineffective in the water - immediately transfer to land or a boat - attempt ventilation if unale to get patient out of the water - consider additional initial ventilations as the injured lung may be harder to ventilate **Spinal immobilisation** •routine cervical spine immobilisation is not necessary -potentially hazardous as vomiting common after drowning, particularly when CPR / ventilation provided •immobilise if circumstances indicate trauma is likely - history of diving - use of a water slide - motor vehicle crash - signs of injury - alcohol intoxication •spinal injury in drowning is associated with clinical features of serious injury **Respiratory support** * focus of initial hospital care * high risk of ARDS up to 72 hours following drowning * alert, cooperative patients do not routinely require tracheal intubation * intubate if pulmonary pathology does not respond to supplemental oxygen and CPAP * if intubation required, support with controlled mechanical ventilation and PEEP - use pressure-support ventilation starting at 10 cm H2O - titrate CPAP or PEEP to maintain SpO2 ≥ 95%, using the lowest possible FiO2 **Other pulmonary therapy** * antibiotics indicated if features of infection develop, guided by culture results * consider antibiotics in paediatric pool drowning (due to aspiration of Pneumococcus in patient's pharynx) -although the evidence for efficacy is weak * use broad spectrum antibiotics prior to culture results if submersion was in grossly contaminated water (e.g. sewerage) * treat bronchospasm * glucocorticoids ineffective for pulmonary complications in drowning **Circulatory support** •initial intravenous fluid therapy should be normal saline -avoid hypotonic solutions •hypovolaemia may be present following prolonged immersion, due to the hydrostatic pressure of the water on the body -correct hypovolaemia but avoid excessive volumes due to the risk of pulmonary oedema * monitor serum electrolytes * invasive monitoring if concerned about intravascular volume -prolonged inotropic support rarely needed •consider ECMO if available **Cerebral resuscitation** * little research in this area * restoration of spontaneous circulation a priority * intracranial pressure management - controversial area - raised ICP may reflect hypoxic injury and treatment may not alter outcome - consider ICP monitor if persistent coma despite correction of reversible causes - target pCO2 25-30 mmHg if ICP raised •induced hypothermia - no convincing evidence for efficacy in drowning - in the comatose patient with spontaneous circulation maintenance of T \< 36C (as for post cardiac arrest) is reasonable •other - avoid hypoxia - treat seizures - prevent hyperthermia at all times - maintain normoglycaemia - insufficient evidence for other specific neuroresuscitative measures **Hypothermia** •manage according to standard protocols

Resuscitation / Critical Illness Flashcards

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