cardiac arrest and trauma Flashcards
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
neonatal oxygenation
first of all, ventilation»_space; oxygenation
term/late-preterm: 21% O2
preterm: 21-30% O2, then titrate to pulse ox
neonatal ventilation
principle: recruitment
PEEP 5-8
fat embolism definition and txx
post-traumatic (esp long bone fx) hypoxemia, neuro deficit, and nondependent petechiae
tx: supportive while sx resolve spontaneously
What complication is typically the cause of death in fat embolism syndrome?
ARDS
Jefferson fracture
C1 burst fracture
axial compression injury
rarely has neuro deficits
needs semi-permanent immobilization (i.e. Halo)
atlanto-occipital dislocation
pure flexion injury that usually kills pt right away
hangman fracture
C2 spondylolisthesis fracture
hyperextension fractures posterior elements of C2
blast injury classes
1 - hollow organ injury
2 - projectiles
3 - thrown
4 - environmental hazard
most common blast injury
TM rupture
2 contraindications to IO placement
fracture, vascular disruption
LeFort fractures
1 = speak no evil (maxilla) 2 = see no evil (infraorbital) 3 = hear no evil (out to the sides)
2 and 3 can give you CSF rhinorrhea
how to dose morphine in chronic pain pts
10% of daily morphine equivalents, then double, then double again
