RESUS AND EMERGENCY PROTOCOLS (27)

Question 1

ALL AGES BLS. (2016)

Answer 1

Upon finding a collapsed casualty, commence resuscitation via the DRSABCD protocol:

• D : DANGER: check for
• R : RESPONSE : check for
  
  • talk n touch
  • squeeze n shout, if none:
• S : SEND for help
• A : AIRWAY : check open
• B : BREATHING : if not breathing normally, go to C and start compressions
• C : CIRCULATION : give 30* compressions at 2/sec, then 2 breaths, then repeat
• D : DEFIBRILLATION : attach SAED ASAP & follow prompts

* NOTE, BLS uses a 30:2 ratio for ALL ages, although ALS introduces the 15:2 ratio for infants and children (?? in recognition of the importance of hypoxia as an aetiology)

Question 2

ALL AGES ALS (2016) (except newborns)

Answer 2

Commence BLS at 30:2 (kids 15:2) and determine rhythm ASAP

1. if SHOCKABLE (VT/VF): Shock immediately at 200J (kids 4J/kg) & commence 2m CPR even if reverts
2. if NON SHOCKABLE (PEA/ASYSTOLE) : - commence 2m CPR & give ADRENALINE 1mg IV/IO asap (kids 10mcg/kg*)

During CPR:

• get O2 in and CO2 out
• get IV or IO access
• consider ETT/LMA
• consider the 4Hs & 4Ts
• Every 2m: do a “CHARGE AND CHECK” and decide:
  
  • another Shock, or
  • more CPR, or
  • post ROSC care
• Every 4m: give ADREN 1mg IV/IO (10 mcg/kg)
• After the 3rd shock: give AMIODARONE 300 mg (kids 5mg/kg)

* 1ml of 1:10,000 per 10kg

Question 3

‘CHARGE AND CHECK’ PROCEDURE DURING RESUSCITATION

Answer 3

When first applying pads, and every 2m thereafter, conduct a ‘CHARGE AND CHECK’ procedure.

1. State “Compressions continue, oxygen and others away**”then CHARGE the defib.
2. When CHARGED, state ‘_Stand Clear_” and CHECK rhythm:

• If SHOCKABLE, confirm all clear, deliver shock, restart 2m CPR
• If NONSHOCKABLE: dump charge and either:
  
  • Restart 2m CPR (if Asystole)
  • Start post ROSC care

Question 4

WHAT TO DO IF AN ICD FAILS TO TREAT VF

Answer 4

• Defibrillate externally as normal, but keep >10cm from the device*

*same same for pacemakers

Question 5

DEFIBRILLATOR PADS AND DRUG PATCHES

Answer 5

• Pads should not be placed over drug patches, remove or avoid

Question 6

PAD POSITION FOR EXTERNAL PACING & CARDIOVERSION

Answer 6

• Place the pads AP over the Left central chest

Question 7

DRUGS GIVEN PERIPHERALLY DURING ARRESTS NEED:

Answer 7

they need a ‘flush and a fly’, ie

• a 20ml flush

and

• a 20 second limb elevation

Question 8

WHAT IS THE ROLE OF INTUBATION DURING CPR?

Answer 8

• Intubation, per se, does not improve survival, but allows continuous compressions which does, so an advanced airway (ETT or LMA) should be considered early in ALS
• Ventilate at 10 breaths per minute after securing the airway

Question 9

OXYGEN THERAPY DURING DEFIBRILLATION?

Answer 9

• If using an open circuit (eg facemask), you should remove the O2 immediately before defibrillation
• If its a closed circuit (LMA/ETT), you can leave it on.

Question 10

FiO2 USED DURING CPR?

Answer 10

• commence with FiO2 of 1.0 until ROSC, then
• titrate to
  
  • 94-98% if N lungs
  • 88-92% if COAD

Question 11

Effective FiO2 during EAR?

Answer 11

• 17%

Question 12

8 REVERSIBLE CAUSES OF CARDIAC ARREST

Answer 12

= the 4H’s and 4T’s

• Hypoxia
• Hypovolaemia
• Hypo/Hyper thermia
• Hypo/Hyper Kalemia, Natremia, Calceamia etc
• Tension
• Toxins
• Tamponade
• Thrombus

Question 13

IN HYPOKALEMIC ARRESTS, GIVE:

Answer 13

• 5mls of KCL (= 5mmol)
• 5mls of MgSO4 (= 10 mmol)

Question 14

MINIMUM DELAY BEFORE ASSESSING OUTCOME POST ROSC

Answer 14

• Generally at least 72h, and in a specialist unit

Question 15

IMMEDIATE POST ROSC CARE

Answer 15

Following a successful resuscitation

1. Optimise the ABCs
2. Ascertain the cause (elecs, 12 Lead etc)
3. Consider ‘Targetted Temperature Management’ (32-36C)

Question 16

SA NEONATAL* RESUSCITATION PROTOCOL. (2011)

Should really be termed ‘newborn’, as neonates are defined as 2h-28d

Answer 16

If vigorous, give to mum, if flat, resuscitate using a modified DRABCD but mask ventilation alone suffices for most

• D = DRY OFF (neonates lose heat easily) and R = RUB: (some apnoeic neonates will breathe if stimulated) : spend 30s doing this then R/V, if still flat go to
• A = AIRWAY : check open, insert guedell
• B = BREATHING : give 15 mask breaths over 30s: (hold button to start/35cm on Neopuff) then check HR and responsiveness : if still apnoiec or HR<60, go to
• C = CIRCULATION : compress* over lower 1/2 of sternum to 1/3 depth, give 3 compressions then 1 breath every 2s, consider #1 LMA or ETT 3.0 at 10cm
• D = DRUGS : use IO or the single umby vein for access then give
  
  • Adren 10mcg/kg (= 0.1ml of 1/10000 per kg, ie typically 0.3mls)
  • NS 10ml/kg (typically 30 mls)

* only use ‘2 handed encircle’ if 2 rescuers, or changeover to resp takes too long

Question 17

ATLS OVERVIEW

Answer 17

• PRIMARY SURVEY
• RESUS AND ADJUNCTS
• SECONDARY SURVEY
• DEFINITIVE CARE

Question 18

ATLS PRIMARY SURVEY

Answer 18

= C-ABCDE:

• Control CATASTROPHIC HAEMORRHAGE
• AIRWAY with CSpine control
  
  • whilst protecting the C spine, ensure open via manipulation, suction, OPA, NPA, LMA, ETT or crike as reqd
• BREATHING
  
  • Oxygen on
  • assess Resp function via RR, WOB, skin colour & oximeter
  • quick chest palp for gross # or air
  • auscultate 2nd & 5th interspaces
• CIRCULATION
  
  • control lesser bleeding, splint #, consider pelvic binder
  • perform FAST and roll to check the back if not already done* for penetrating trauma
  • assess Circulation via Consc state, HR, pulse volume & perfusion
• DEFICIT
  
  • GCS & pupils
  • rapid limb assessment for gross sensory/motor loss
• EXPOSURE
  
  • undress fully to examine but keep warm

* may be done at initial transfer onto resus bed

Question 19

ATLS PRIMARY SURVEY ADJUNCTS

Answer 19

By the end of the PRIMARY SURVEY, and the RESUS AND ADJUNCTS phase that follows it, you should complete:

• IVT x 2 and full set of bloods
• consider NGT and IDC
• Imaging: neck, chest, abdomen (FAST) & pelvis
• full monitoring including temperature

Question 20

ATLS SECONDARY SURVEY

Answer 20

= AMPLE Hx: Allergies/Meds/Past Hx/Last Meal/Events leading to the trauma and ‘Head to toe’ exam:

• HEAD: scalp, ears, eye ROM & acuity, face, mouth, cranials
• NECK: clear if able, ausc carotids/vertebrals
• CHEST: inspect, palpate clavs/ribs/sternum, percuss, auscultate
• ABDO : inspect, palpate, percuss, auscultate
• PELVIS: pull in then out (unless # known)
• BACK: 4 person roll if not already done check back, PR, consider PV if injury suspected
• ARMS & LEGS : bones, joints, pulses, sensation, power, reflexes

* eg pelvic # or penetrating injury

Question 21

FMC MASSIVE TRANSFUSION PROTOCOL 2012

Answer 21

If massive transfusion anticipated: notify lab and commence MTP immediately:

1. Control bleeding with direct pressure, permissive hypotension & DCS
2. Start PACK ONE
   
   • RBC x 5U O Neg (O pos OK)
   • FFP x 4U AB Pos (A Pos or AB Neg OK)
   • Plates x 1 ‘Four pack’ (unmatched)
3. Consider TRANEXAMIC ACID 1g IV over 10/60 then 8/24
4. Use PACK 2,3 etc
5. Aim for
   
   • Temp > 35C
   • Platelets > 50,000
   • INR < 1.5 and APTT< 60*, or give more FFP
   • Ca++ > 1.1
   • Fibrinogen > 1.0g/L**, or give 4U Cryo
   • pH > 7.2, Lactate < 4mmol/L and BE < -6)
6. rF7a remains unproven, but may consider 90mcg/kg IV in consultation with Lab

• * obviously TEG now*
• ** N is >2g/L*

Question 22

CRISIS COVER

Answer 22

• C: call for help, Colour, Carotids, Conscious state
• O: Check Oximeter, O2 to 100%
• V: Ventilator off, Vaporiser off
• E: check ETT, Exterminate the machine
• R: remember PT, remember Anaphylaxis

Question 23

ANAPHYLAXIS IMMEDIATE MANAGEMENT

Answer 23

1. DIAGNOSE IT
   
   • likely: if rash + hypotension + bronchospasm, possible if any 1
2. DECLARE IT
   
   • “this could be anaphylaxis”, get help, get box, read card…
3. DISCONTINUE TRIGGERS
   
   • relaxants, antibiotics, colloids, chlorhex, latex
4. START IMMEDIATE MANAGEMENT (ABCs & Adrenaline)
   
   • Airway: support as required
   • Breathing:- 100% O2, if IPPV: use SMALL, SLOW breaths
   • Circulation:
     
     • if absent give Adrenaline 1mg IV (kids 10mcg/kg), fluids 20ml/kg and commence ALS
     • otherwise give Adren 100 mcg* IV prn (severe) or 10 mcg (mild), consider infusion
     • if no IV/IO access, give neat ADREN IMI into lateral thigh, 500mcg Adults, 300mcg large children, 150 mcg small children

* kids = 5mcg/kg

Question 24

ANAPHYLAXIS, REFRACTORY MANAGEMENT

Answer 24

If poor response:

1. CONFIRM TRIGGERS STOPPED
2. QUESTION THE DX:
   
   • get more information: TOE, elecs, gas, ecg, CXR etc
   • Is this high airways resistance from asthma, aspiration, tube kinked or blocked
   • is this low CO2 from oesophageal intubn, gas embolus or cardiac arrest
   • is this hypotension from hypovolaemia, MI, high spinal
   • is this swelling from Angioedema
   • still dont know: 4H & 4T
3. ESCALATE RX
   
   • For resistant Hypotension:
     
     • NORAD
     • VASOPRESSIN: 20u in 40mls, 1ml stat then 4-1 mls/h
     • GLUCAGON (reverses BBlockers) : 1-5 mg slow IV
   • For resistant Bronchospasm:
     
     • consider AutoPeep : test disconnect
     • SALBUTAMOL IV: 3mg in 50mls: LD 4mls slow IV (240mcg) then 1-20 mls/h
     • STEROIDS & ANTIHISTAMINES : have now been deleted from acute management algorithms as they have no proven benefit !!

Question 25

TREATMENT OF LA TOXICITY

Answer 25

1. Recognise the signs and symptoms, which can be delayed 30m
   
   • agitation, tremors, seizures
   • circumoral numbness and metallic taste
   • Diplopia and tinnitus
   • tachy then bradyarrhythmias and asystole
2. address the ABCs via ALS
3. LIPID RESCUE with 100mls of 20% INTRALIPID IV, repeat x several (not Propofol : insufficient lipid)

Question 26

MALIGNANT HYPERTHERMIA MECHANISM & RX

Answer 26

• MH is a syndrome characterised by runaway oxidative metabolism in skeletal muscle triggered by SCOLINE or VOLATILES, and producing muscle rigidity and breakdown, hyperthermia, hyperkalemia, hypercarbia and acidosis
• it occurs in humans, pigs, dogs, and horses and the cause is a hereditary defect in the RYANODINE RECEPTOR (a protein controlling Ca metabolism in skeletal muscle)

MH TREATMENT

• stop trigger: vapour off, hyperventilate pt with high flow O2 but dont bother removing circuit/vaporiser etc
• address the ABCs
• start TIVA
• DANTROLENE 2.5 mg/kg IV stat, repeat x several
• cool with 4C RINSE and surface ice
• ICU Monitoring of elecs etc

Question 27

TURP SYNDROME MECHANISM & TREATMENT

Answer 27

Excessive absorption of the GLYCINE irrigant into the vascular space during TURP can cause HYPERVOLAEMIA & HYPONATREMIA (<120), producing

• SOB
• visual changes
• agitation and confusion
• seizures

Rx

• stop surgery
• address the ABCs
• correct the hyponatremia slowly*
  
  • change IVT to NS
  • consider Hypertonic saline
  • consider diuretics

*don’t correct HYPONATREMIA too rapidly or CENTRAL PONTINE MYELINOSIS