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Advanced Life Support (ALS) > Chapter 12: Resuscitation in Special Circumstances > Flashcards

Chapter 12: Resuscitation in Special Circumstances Flashcards

1
Q

What happens to potassium in acidosis?

A

Serum K+ increase as it moves from cells to serum

H+/K+ pump

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2
Q

How is hyperkalaemia defined and what classifies as severe?

A

K+>5.5mmol/L

Severe >6.5mmol/L

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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

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4
Q

What ECG changes do you see with hyperkalaemia?

A 
Absent/small p waves
Long PR
Tall tented t waves
Wide QRS
Can see ST segment depression

S and T merging
VT
Bradycardia
Cardiac arrest

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5
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
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6
Q

What do you do for each stage of hyperkalaemia?

A

Mild: 5.5-5.9

  • Address cause
  • Calcium resonium (bind to calcium)

Mod: 6.0-6.4

  • Insulin dextrose infusion
  • Address cause
  • Calcium resonium

Severe: 6.5+

  • Expert help
  • Calcium gluconate
  • Insulin dextrose infusion
  • Address cause
  • Salbutamol nebulisers back to back
  • Calcium resonium
  • Remove K+ - dialysis

To give calcium gluconatecalcium chloride if ECG changes.
Repeat ECGs

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7
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

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8
Q

How is hypokalaemia defined?

A

<3.5mmol/L

Severe = <2.5mmol/L

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9
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+

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10
Q

How can you recognise hypokalaemia?

A
  • Rule out 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
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11
Q

What ECG features are seen in hypokalaemia?

A 
U waves
Small t waves
Tall P waves
ST segment changes
Arrhythmia's
Cardiac arrest
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12
Q

How should K+ be replaced?

A

Gradually
Max 10mmol/L per hour on normal ward
Ma 20mmol/L per hour in HDU/ICU

More rapid infusion indicated in unstable arrhythmia - 2mmol/L/min for 10 mins then 10mmol over 5-10 mins

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13
Q

What can cause hypercalcaemia? (>2.6mmol/l)

A

Primary/tertiary hyperparathyroid
Malignancy
Sarcoid
Drugs

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14
Q

How does hypercalcaemia present?

A 
Confusion
Weakness
Abdo pain
Hypotension
Arrhythmia
Cardiac arrest
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15
Q

What ECG changes are seen in hypercalcaemia?

A 
Short QT
Wide QRS
Flat t waves
AV block
Cardiac arrest
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16
Q

How is hypercalcaemia treated?

A 
Fluid replacement
Furosemide - 1mg/kg
Hydrocortisone 200-300mg
Pamidronate 30-90mg/ bisphosphonates
Treat underlying cause
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17
Q

What can cause hypocalcaemia? (<2.1mmol/l)

A 
Chronic renal failure
Pancreatitis
Calcium channel blocker OD
Toxic shock syndrome
Rhabdomyolysis
TLS
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18
Q

How does hypocalcaemia present?

A 
Paraesthesia
Tetany
Seizures
AV block
Cardiac arrest
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19
Q

What ECG changes are seen for hypocalcaemia?

A

Prolonged QT
T wave inversion
Heart block
Cardiac arrest

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20
Q

What can cause hypermagnasaemia? (>1.1mmol/l)

A

Renal failure

Iatrogenic

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21
Q

How does hypermagnasaemia present?

A 
Confusion
Weakness
Resp. depression
AV block
Cardiac arrest
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22
Q

What ECG changes are seen for hypermagnasaemia?

A

Prolong PR and QT
T wave peak
AV block
Cardiac arrest

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23
Q

How is hypermagnasaemia managed?

A

Calcium chloride 10ml 10%
Ventilatory support if req.
Saline diuresis - furosemide 1mg/kg+0.9% saline
Haemodialysis

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24
Q

What can cause hypomagnasaemia? (<0.6mmol/l)

A 
GI loss
Polyuria
Starvation
Alcohol
Malabsorption
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25
How does hypomagnasaemia present?
``` Tremor Ataxia Nystagmus Seizures Arrhythmia - torsades Cardiac arrest ```
26
How does hypomagnasaemia present on ECG?
``` Prolong PR and QT ST depression T wave inversion Flat p waves Wide QRS Can get polymorphic VT - torsades ```
27
How is hypomagnasaemia managed?
2g 50% MgSo4 (4ml 8mmol/L) - mild = oral replacement (0.5-0.8) - severe = over 15 mins - torsades = over 1/2 mins - Seizure = over 10 mins
28
How to manage sepsis
Sepsis 6 - 02, Blood cultures, lactate, Abx, fluids, urine output
29
What specific treatments are available for poisoning?
Skin exposure - remove clothes Activated charcoal - <1hr and intact airway Whole bowel irrigation using polyethylene glycol Sodium Bicarb IV - salicylate poisoning and amitriptyline Haemodialysis Specific antidotes
30
What is the specific antidote for paracetamol?
N-acetylcysteine
31
What is the specific antidote for organophosphate poisoning?
High dose atropine
32
What is the antidote for cyanides poisoning?
Sodium nitrite Hydroxocobalamin Amyl nitrite
33
What is the antidote for digoxin poisoning?
Digibind - digoxin specific Fab antibodies
34
What is the antidote for benzodiazepines?
Flumazenil if no risk of seizure
35
What is the antidote for opioid poisoning?
Naloxone 400mcg IV, 800mcg IM, 800mcg SC or 2mg Intranasal Non IV may be quicker - save time getting access Duration of action not as long as respiratory depression persist - give increments until breathing adequately Can give naloxone infusion
36
What does opioid poisoning cause?
Resp depression Pinpoint pupils Coma following resp. arrest
37
What happens if opioids are withdrawn acutely in poisoning?
State of sympathetic excess leading to complications: - Pulmonary oedema - Ventricular arrhythmia - Severe agitation Use naloxone cautiously in patients with dependence
38
What can a benzodiazepine OD cause?
Loss of consciousness Respiratory depression Hypotension
39
What can reversal of benzodiazepine OD with flumazenil lead to in patients with dependence or have coinjested pro-convulsants?
Seizure Arrhythmia Hypotension Withdrawal syndrome
40
Is flumazenil used in comatose patients?
No
41
What can tricyclic antidepressant OD cause?
Hypotension Seizure Coma Life-threatening arrhythmia - commonly shockable Anti-cholinergic effects - mydriasis, fever, dry skin, delirium, tachycardia, ileus, retention
42
What may indicate that a TCA overdose will lead to arrhythmia?
Wide QRS Right axis deviation Usually noted with prolonged QT Consider sodium bicarb
43
When can you get local anaesthetic toxicity?
Regional anaesthesia - enters artery or vein
44
What issues can you get with local anaesthetic toxicity?
Severe agitation Loss of consciousness with or without tonic-clonic convulsions Sinus Bradycardia/ Conduction blocks/Asystole/VT
45
How can local anaesthetic toxicity be treated?
Resus measures IV 20% lipid emulsion - initial 1.5mL/kg/hr bolus in 1 min followed by 15mL/kg/hr infusion - Give upto 3 boluses at 5 min intervals - Max 12mL/kg emulsion
46
What can cocaine toxicity cause?
Sympathetic overstimulation: - agitation - symptomatic tachycardia - hyperthermia - hypertensive crisis - myocardial ischaemia with angina
47
What can be done to treat cocaine toxicity?
Small dose IV benzo (midazolam, diazepam, lorazepam) GTN and phentolamine - reverse coronary vasoconstriction Can consider beta blockers and anti-arrhythmics - best unclear Use normal adrenaline dose if arrest
48
How is drug induced severe bradycardia managed?
Atropine - organophosphate, carbamate, nerve agent poisoning or acetylcholinesterase inhibitors 2-4mg IV repeated doses
49
What can be used to treat bradycardia due to beta blockers or calcium channel blockers?
Can use Isoprenaline at high dose if refractory bradycardia due to beta blockers Vasopressors, inotropes, calcium, glucagon, phosphodiesterase inhibitors and high dose insulin-dextrose-potassium infusions
50
What can cause cardiorespiratory arrest in asthmatic patients?
- Severe bronchospasm and mucous plugging --> asphyxia - Hypoxia --> cardiac arrhythmia. Can also be due to drugs or electrolyte abnormalities - Dynamic hyperinflation in mechanically ventilated - reduced venous return and BP - Tension pneumothorax
51
What signs indicate acute severe asthma?
- PEFR 33-50% - RR >25 - HR >110 - Inability to complete sentence in 1 breath
52
What signs indicate life-threatening asthma?
``` Altered conscious level Exhaustion Arrhythmia Hypotension Cyanosis Silent chest Poor resp effort ``` PEFR<33 SpO2 <92% PaO2 <8kPa 'normal' PaCO2 - 4.6-6
53
What indicates asthma mat be near fatal?
Raised PaCO2 and/or mechanical ventilation with raised inflation pressures
54
What may absence of wheezing in asthma indicate?
Critical airway obstruction Increased wheezing may indicate + response to therapy
55
What can happen to SpO2 in SABA therapy of asthma?
May initially decrease as beta agonists cause bronchodilation and vasodilation - increased intra pulmonary shunting
56
How can acute asthma attacks be managed?
- High flow O2 - sats of 94-98% - Salbutamol 5mg neb - repeat every 15-30 mins or cont. 5-10mg/hr - Add neb ipratropium bromide 500mcg 4-6hr - Prednisolone 40-50mg PO or hydrocortisone 100mg IV Can give IV Magnesium sulphate 2g (8mmol) over 20 mins Consider IV salbutamol 250mcg if inhaled not possible Senior advice for aminophylline - 5mg/hr IV 20 min then 500-700mcg/kg/hr infusion (max dose 20mcg/mL to avoid toxicity)
57
What can beta agonist and steroid therapy in asthma cause?
Hypokalaemia
58
When should tracheal intubation and controlled ventilation be considered in asthma?
``` Deteriorating peak flow Reduced conscious level Persisting/worsening hypoxaemia Worsening resp. acidosis Severe agitation, confusion and fighting against o2 mask Progressive exhaustion Cardioresp. arrest ``` Role of non invasive ventilation unclear - only considered in ICU setting
59
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
60
What is important to remember about recognising anaphylaxis?
Skin and mucosal changes alone not a sign Skin and mucosal changes can be subtle/absent Can be GI symptoms - abdo pain as blood and fluid redirected away from gut
61
How is anaphylaxis managed in an adult?
``` Remove trigger Lie down + legs up IV Fluid challenge 500-1000ml IV chlorphenamine 10mg IV hydrocortisone 200mg IM Adrenaline 0.5mg (0.5ml of 1:1000) - anterolateral middle thigh - repeat at 5min mark if no response with fluid bolus ```
62
When can IV adrenaline be used in anaphylaxis?
Only by specialists Can cause hypertension, tachycardia, ischaemia, arrhythmia if spontaneous circulation May be used if repeated IM doses Max 50mcg in adults and 1mcg/kg in children
63
How can anaphylaxis be investigated?
Mast cell tryptase - 3 timed samples: - ASAP after resus - 1-2hr after start of symptoms - 24hr after
64
How is haemorrhage in pregnancy managed in cardiac arrest?
Fluid Resus Tranexamic acid and correct coagulopathies Oxytocin, ergometrine, prostaglandins and uterine massage for uterine atony Uterine compression sutures, packs or intrauterine balloon devices Surfical control - aortic cross clamp/compression and hysterectomy. Placenta percreta may req. intra-pelvic surgery
65
How is pre-eclampsia treated?
Magnesium sulphate - prevent eclampsia in labour
66
How are amniotic fluid emboli managed?
Supportive | Correct coagulopathies
67
What are the key causes of cardiac arrest in trauma patients?
``` Severe traumatic brain injury Hypovolaemia Hypoxia Tension pneumothorax Direct injury to vital organs Cardiac tamponade ```
68
What is a key focus of traumatic cardiac arrest management? What may be helpful to use in these cases?
Correct the reversible causes Do chest compressions but unlikely to be successful without correction FAST scan or CT may be useful in guiding treatment Early tracheal intubation can be beneficial
69
What can happen if positive pressure ventilation is used in low cardiac output conditions?
Further circulatory depression by impeding venous return
70
How are tension pneumathoraces managed in traumatic cardiac arrest?
Needle decompression - 2nd intercostal space midclavicular line
71
How is a cardiac tamponade managed?
Resuscitative clamshell thoracotomy Needle aspiration unreliable - pericardium commonly full of clotted blood
72
When should resuscitative thoracotomies be considered?
Penetrating torso trauma and <15min CPR Blunt trauma and <10min prehospital CPR No pulse after penetrating chest or cardiac injuries and signs of life or ECG activity
73
What are the commonest causes of anaesthesia related cardiac arrest?
Airway management
74
What are the most common rhythms seen in peri op cardiac arrest?
Asystole - 41% | VF - 35%
75
What is drowning and what are the "types"?
Respiratory impairment from submersion/immersion in liquid Submersion - face underwater/covered by water Immersion - head remain above water - e.g. life jacket
76
What typically happens to patients who are immersed in water?
Become hypothermic Airway remain patient Water splashes can cause aspiration
77
What happens in submersion?
Patient initially hold breath and swallow water As pt. become hypoxic and hypercapnic, breath holding reflex and laryngospasm reflex lost. Patient aspirate water Laryngospasm reflex prevent water entering lungs Bradycardia due to hypoxia occur before sustaining cardiac arrest
78
How do you attempt to rescue someone from the water?
Ideally throw rope or buoyant rescue aid Assess risk and enter with flotation device If submersion for <10 mins - likely good outcome. If >25 mins - likely poor outcome Remove from water horizontally - spinal precautions rarely necessary
79
Why remove patients horizontally from the water?
Hypovolaemia after prolonged immersion can cause cardiovascular collapse and arrest
80
What initial rescue should you do for patients once retrieved from the water?
Check for response Give 5 rescue breaths with supplemented oxygen Start CPR as normal If lots of foam - continue CPR until intubation Turn victim to side and remove regurgitation material
81
What is important about post resus care after drowning?
Risk of developing ARDS - use standard protective ventilation stratefies Consider ECMO for refractory cardiac arrest, hypoxaemia and submersion in ice cold water Pneumonia common however prophylactic Abx only if sewage/grossly contaminated Neurological outcome determined by hypoxia
82
Define hypothermia
<35 degrees
83
What may increase risk of hypothermia?
Things that decrease conscious level - drugs, alcohol, illness, exhaustion, neglect Factors that impair thermoregulation - elderly and very young
84
Why must you be careful diagnosing death in hypothermic?
Patients can have slow small volume irregular pulses and low BP but they may return once warm Not dead until warm and dead At 18 degrees, brain survive 10 times as long from circulatory arrest than at 37 Good survival has been reported in arrest and core temp of 13.7 degrees after immersion for 6.5 hours with CPR in adults
85
How should CPR be modified in hypothermic patients?
<28 degrees 5 min CPR, 5 min break <20 5 min CPR, 10 min break Check for pulse for 1 minute - central artery and ECG Consider using mechanical chest compression Dont delay intubation Hold adrenaline and amiodarone until >30 degrees. Then double dose interval (6-10 mins) until 35 degrees
86
How are arrhythmia's treated in hypothermia?
Sinus Brady --> AF --> VF --> asystole Apart from VF, others revert spontaneously as temp increase. Cardiac pacing not indicated unless haemodynamic compromise persist after rewarming Stop shocks after 3 until temp >28-30
87
When are avalanche victims not likely to survive?
Buried for >60 mins and in cardiac arrest with obstructed airway on extraction Buried and in cardiac arrest with K+ >8mmol/L
88
What other active rewarming techniques can be used?
Forced warm air Warm infusions Forced peritoneal lavage
89
What are the stages of hyperthermia?
Heat stress Heat exhaustion Heat stroke --> multi-organ dysfunction and cardiac arrest
90
What is heat stroke?
Core temp >40.6 Change in mental state Varying levels of organ dysfunction 2 types: - exertional - non exertional - elderly in heat waves
91
What can predispose someone to heat stroke?
Elderly: - underlying illness - medication use - declining thermoregulatory mechanisms - limited social support ``` Lack of acclimitisation Dehydration Alcohol Obesity CVS conditions Skin disease Hyperthyroidism Phaeochromocytoma ```
92
What drugs can predispose to hyperthermia?
``` Anticholinergics Diamorphine Cocaine Methamphetamine Phenothiazines Sympathomimetics Ca2+ blockers Beta blockers ```
93
What are the features of heat stroke?
``` Core Temp >40 Hot dry skin Fatigue, headache, fainting, facial flush, D&V CVS dysfunction - arrhythmia and hypotension Resp dysfunction - ARDS CNS dysfunction - seizures and coma Liver and renal failure Coagulopathy Rhabdomyolysis ```
94
What differentials do you have to consider for raised core temperature?
``` Drug withdrawal syndromes Neuroleptic malignant syndrome Sepsis CNS infection Endocrine disorder - thyroid and phaeochromocytoma ```
95
How is heat stroke treated?
Rapid cooling Haemodynamic monitoring - fluid and electrolytes Defibrillation as normal Post resus care as normal
96
What is used in treatment of malignant hyperthermia?
Dantrolene
97
What reduces skin resistance to electrocution?
Moisture
98
What can cause myocardial or respiratory failure in electrocution?
Resp arrest due to paralysis of respiratory muscles or resp depression Current can precipitate VF if it crosses myocardium during vulnerable period. Current can cause coronary artery spasm Asystole ma be primary or secondary to asphyxia following resp arrest
99
In patients who survive an initial electric shock, what may happen?
Catecholamine release or autonomic stimulation: - tachycardia - hypertension - prolonged QT and transient t wave inversion - myocardial necrosis - CK release
100
What determines long term prognosis for electrical injury?
Severe burns Myocardial necrosis Extent of CNS injury Multiple system organ failure
101
What level of potassium definetely causes ECG changes
6.7mmol l
102
What other electrolyte to check with hypokalaemia
Mg
103
What is refractory anaemia
No improvement of cardiovascular or respiratory symptoms despite 2 doses of adrenaline Give - IV 500ml bolus and adreanlaine infusion

Advanced Life Support (ALS) (9 decks)

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