ERC - special circumstances Flashcards
Is hypoxia due to apnoea or due to airway obstruction likely lead to arrest first and why?
airway obstruction
Patient trying to breathe against the obstruction which increases oxygen demand therefore leading to hypoxic cardiac arrest quicker
Name some causes of asphyxial cardiac arrest
laryngospasm, asthma, spinal cord injury, drowning, pneumonia, tension pneumothorax
What K level is considered hyperkalaemia
> 5.5 mmol/L
State some cause of hyperkalaemia
metabolic acidosis (inc diabetic keto)
ACEi, ARB, Bblocker, NSAIDs
rhabdomyolysis
AKI
What ECG changes are you looking for in hyperkalaemia
Rate: Bradycardia, VT flat P wide QRS Peaked T Sine wave - S and T merge
A long transit time would lead to hyper or hypo kalaemia
hyper - K released in the clotting process
Management of a mild hyperkalaemia (5.5-5.9mmol/L)
Calcium resonium 15g 4x/day oral -
Management of moderate (6-6.4) and severe (>6.5) hyperkalaemia without ECG changes
25g glucose (50ml 50%) + 10 unit soluble short acting insulin IV over 10 minutes \+ calcium resonium or dialysis
Management of moderate (6-6.4) and severe (>6.5) hyperkalaemia with ECG changes
10ml 10% calcium chloride IV over 2-5 minutes
repeat dose after 5 minutes if needed
+ 25g (50ml 50% glucose) and 10 units insulin
+ calcium resonium or dialysis
+ salbutamol nebulisers 10-20mg
In which patients hyperkalaemic would you consider dialysis
end stage renal failure
oliguric AKI
rhabdomyolysis
Define mild, moderate and severe hyperkalaemia
mild 5.5-5.9
moderate 6-6.5
severe >6.5
What monitoring is needed during hyperkalaemia management
pottasium
ECG
glucose (risk of hypo due to treatment)
A hyperkalaemic patient has severe acidosis or renal failure, what additional drug would you consider
sodium bicarbonate
signs of hyperkalaemia
parasthesia
loss of deep tendon reflex
flaccid paralysis
signs of hypokalaemia
fatigue
weakness
cramps
constipation
K level defining hypokalaemia
<3.5mmol/L
causes of hypokalaemia
diarrhoea K losing diuretics metabolic alkalosis hypomagnesaemia steroids
ECG signs of hypokalaemia
Flat T
U wave
Management of hypokalaemia
replace K slowly unless emergency in which case you can give 20mmol/hr
Management of a tension pneumothorax
intubate, PPV and decompress the chest
Why is a needle decompression not often used
Chest wall thickness often too thick for it to work
Describe a thoracostomy in tension pneumothorax management
PPV
cut and then dissect to reach the pleural cavity
a chest tube can then be inserted
Describe some general management options to decontaminate and enhance elimination of poisons
50-100g activated charcoal
whole bowel irrigation
haemodyalysis
benzodiazepine toxicity management
flumazenil
opioid toxicity management
400 micorgrams naloxone
TCA toxicity presentation
VT
hypotension
seizures
TCA toxicity management
sodium bicarbonate 1-2mmol/kg
B blocker toxicity management
limited evidence but can try glucagon or insulin and glucose
CCB toxicity management
20ml 10% calcium chloride
Digoxin toxicity management
Digoxin-FAB antidote
cyanide toxicity management
hydroxycobalabamin
sodium thiosulfate
Which benzo toxicity patients would you not give flumazenil to
if they coingested TCAs
aspirin toxicity management
urinary alkalinisation with IV sodium bicarbonate
Brief overview of traumatic CA management
treat the reversible causes. These take priority over compressions
- hypovolaemia - control catastrophic haemorrhage
- hypoxia - control airway
- tension pneumothorax - bilateral chest decompression
- tamponade
how is external haemorrhage controlled
direct pressure, torniquet, pelvic binder
blood products
TXA 1g over 10 minutes
further 1g infused over 8 hours
how is airway managed in traumatic CA
immediate intubation if possible but if not SGA
how should a traumatic CA patient be ventilated and why
Low tidal volume and rate as aggressive ventilation and PPV leads to increased intrathoracic pressure and therefore reduced diastolic filling and reduced CO
aim for normocapnoea
You are with a traumatic CA patient, they arrested <10 minutes ago, you have the expertise, equipment and right environment, what do you do
consider a resuscitative thoracotomy
when is a resuscitative thoracotomy considered
cardiac arrest <10 minutes ago + penetrating chest/epigastrium injury + expertise, equipment and environment suitable
when in CPR stopped in traumatic CA
all reversible causes addressed
15 minutes downtime
obvious mortal injury
no cardiac activity on USS
a traumatic CA patient reaches hospital, what happens now
damage control resuscitation:
permissive hypotension + haemostatic resuscitation + damage control surgery
describe permissive hypotension
Fluids given to maintain:
systolic pressure at 80-90
radial pulse
describe haemostatic resuscitation
ratio of packed red cells: platelets: FFP is 1:1:1
What should you look for when diagnosis anaphylaxis
acute onset
life threatening problems with airway, breathing, circulation
skin or mucosal changes
Initial steps (before drugs) in anaphylaxis management
remove trigger
call for help
lie patient flat with legs raised (unless their breathing is easier sat up)
Anaphylaxis drug management
IM Adrenaline 500 micrograms (0.5ml 1:1000)
IM or slow IV Chlorphenamine 10mg
IM or slow IV Hydrocortisone 200mg
IV fluid challenge 500-1000ml crystalloid
how does adrenaline work in anaphylaxis
alpha agonist: reverse peripheral vasodilation
B agonist: airway dilation, increased cardiac force of contraction, inhibits activation of mast cells so stops them releasing histamine
A patient in anaphylaxis goes into arrest: how are they managed
Standard ALS adrenaline doses
your anaphylaxis patient doesn’t improve after the first dose of adrenaline, what do you do
repeat the dose every 5 minutes
MOA of chlorphenamine
H1 antihistamine which counters vasodilation and bronchoconstriction
You arrive at the scene of an avalanche: in what situations would you not start CPR
can’t safely get to the victim
obvious mortal injury
whole body frozen
You find a patient at the scene of an avalanche, what 2 factors determine using the standard ALS algorithm or not
duration of burial <60 minutes
temperature >30 degrees
Your avalanche burial victim has been there for >60 minutes or is <30 degrees, what do you assess next
signs of life - spontaneous breathing or palpable pulse
check for 1 minute
Your avalanche burial victim has been there for >60 minutes or is <30 degrees and has signs of life, now what
transport them to a hospital that can provide ECLS
Your avalanche burial victim has been there for >60 minutes or is <30 degrees and has no signs of life. Compare your management strategy in regards to the different arrest rhythms
VF/pVT/PEA - transport them to a hospital that can provide ECLS
asystole with patent airway - test potassium
asystole with no patent airway - termination of CPR
your avalanche burial victim is in asystole with a patent airway and you have measured their potassium, describe what results would lead to what management decision
> 8mmol/L: consider termination of CPR
<8mmol/L: transport to hospital that can provide ECLS
What do you need to consider as a cause for a raised potassium in an avalanche burial victim
crush injuries
if any depolarizing neuromuscular blocking agents have been used
What is commotio cordis
disruption of the cardiac rhythm due to a blow to the precordium
what is the ETCO2 goal signifying effective CPR
> 2.7Kpa (20mmHg)
define submersion vs immersion
submersion - the patients face is underwater
immersion - the patients head remains above water
What reflex occurs on being submersed in water and what does this lead to
breath holding reflex - lead to hypoxia (and therefore bradycardia) and hypercapnia
eventually the laryngospasm relaxes and the patient aspirates water
what leads to collapse on being rescued from water
The loss of hydrostatic pressure that the water has been providing leads to hypovolaemia
Principles of managing a drowning victim
keep them horizontal
open airway
5 rescue breaths + O2 if possible
drowning victims often have increased airway resistance. What does this mean for your management
SGA may not provide adequate inflation pressures so intubate asap
increased risk of gastric inflation and aspiration
What causes later complications in drowning victims
surfactant has been washed out
What are some altitude related illnesses
acute mountain sickness - headaches, nausea, dizzy
high altitude pulmonary oedema - cyanosis, SOB
high altitude cerebral oedema - confused, disorientated, odd gait
treatment of a patient suffering from altitude related illnesses
get them down O2 hyperbaric chamber dexamethasone for cerebral oedema nifedipine for pulmonary oedema
What injuries/illnesses should be examined for in a patient that has been electrocuted
fractures - from sustained tetanic muscle contraction
respiratory muscle paralysis
VF from the electrical current
ischaemia - from coronary vasospasm
A patient survives the initial electrocution, what can then happen to lead them to being unstable
catecholaminergic surge - raised BP, long QT, T inversion
management strategies for an electrocution patient
intubate if facial burns
c-spine if fall
ventilation for respiratory muscle paralysis
fluids for tissue destruction
You are at a major incident and come across a patient that isn’t breathing, what do you do
Look listen feel for 10 seconds
nothing = dead
something = recovery position and move on
what is auto-peep in asthmatics and what does it lead to cardiovascularly
air flow does not return to zero at the end of exhalation. Air enters and cannot escape meaning that intrathoracic pressure rises and venous return falls
you give an asthmatic a B-agonist and there sats go down, why could this be
vasodilation and bronchodilation leads to increased shunting
asthma emergency management
5mg nebulised salbutamol every 15 minutes 0.5mg ipatropium bromide every 4 hours \+/- I00mg hydrocortisone \+/- IV magnesium sulphate \+/- IV salbutamol \+/- aminophylline
An asthmatic patient goes into arrest, what alterations need to be made to standard ALS
early intubation
ventilate at a rate of 8-10/minute
may need to increase defibrilation energy to overcome increased impedance from air trapping
What is a ventricular assist device
pump that assists in moving blood from ventricles to great vessels (most common type is LVAD so LV to aorta)
how can cardiac arrest be diagnosed in someone with a ventricular assist device
The device pump will tell you
arterial line and CVP give the same readings
echo
Describe the management of VF,pVT, asystole and PEA in someone with a ventricular assist device
VF/pVT - defib as normal
asystole - pacing
PEA - turn pacing off and check for underlying VF
ipatropium bromide MOA
anticholinergic so increases bronchodilation
causes of cardiac arrest in pregnancy
haemorrhage, PE, eclampsia, genital tract sepsis
At what week gestation does aortocaval compression begin to effect venous return and BP
> 20 weeks
Changes to emergency management when the patient is pregnant
left lateral title to 15 degrees or manually displace the uterus
hand position for compressions higher
smaller tracheal tube due to the airway oedema associated with pregnancy
shock as normal
methods to control haemorrhage in a pregnant patient
cell salvage
oxytocin and prostoglandin analogues
massage uterus
balloon tamponade
at what week gestation would you start to consider resuscitative hysterectomy
> 20 weeks
until 24 weeks this is just for mothers sake
management of eclampsia
magnesium sulphate
why is early intubation needed in pregnancy arrest
increased abdominal pressure = harder to ventilate lungs
relaxed oesophageal sphincter = aspiration risk higher
What would make you think someone was having an acute severe asthma attack
HR >110
RR >25
can’t complete sentence in one breath
What would make you think someone was having a life threatening asthma attack
sats <92% PaO2 <8 normal PaCO2 (4.6-6) hypotensive cyanotic silent chest altered conscious
What would make you think someone was having a near-fatal asthma attack
hypercapnia
Normal range of calcium
2.1-2.6mmol/L
causes of hypercalcaemia
primary hyperparathyroidism
malignancy
symptoms of hypercalcaemia
moans, groans and stones
ECG of hypercalcaemia
short QT
flat T
AV block
osborn waves (mimic hypothermia)
management of hypercalcaemia
fluids
furosemide, hydrocortisone, pamidronate
causes of hypocalcaemia
CCB OD
chronic renal failure
rhabdomyolysis
symptoms of hypocalcaemia
tetany
parasthesias
seizures
management of hypocalcaemia
20ml 10% calcium chloride
4-8mmol MgSO4
ECG changes of hypocalcaemia
prolonged QT
T inversion
AV block
normal range of Mg
0.6-1.1mmol/L
causes of hypermagnesaemia
renal failure
symptoms of hypermangnesaemia
weak
confused
respiratory depression
ECG changes in hypermagnesaemia
Prolonged PR and AV block
Prolonged QT
peaked T waves
management of hypermagnesaemia
only required when Mg >1.75mmol/L
10ml 10% calcium chloride
saline
furosemide
symptoms of hypomagnesaemia
tremor
ataxia
nystagmus
seizures
ECG changes of hypomagnesaemia
Prolonged PR Prolonged QT - TdP Wide QRS ST depression T inversion
management of hypomagneseaemia
2g 50% MgSO4 IV
causes of hypomagnesaemia
GI loss
starvation and malabsorption
alcoholism
A patient has an arrest with a shockable rhythm whilst in the cath lab, how are they managed
3 stacked shocks
CPR with a mechanical device (high quality and reduced radiation to CPR provider)
A patient was fitted with a VAD less than 10 days ago and has an arrest that doesn’t respond to defibrillation, what do you do
emergency resternotomy
Name a differential for ECG features suggestive of ACS
subarachnoid haemorrhage
a patient has an arrest following major cardiac surgery - how should they be managed
if adequate airway and ventilation control and 3 stacked shocks (if VF/pVT) have not worked then undertake emergency resternotomy
a patient goes into arrest whilst undergoing haemodyalysis, what is the most likely cause and rhythm
hyperkalaemia
shockable
you suspect dynamic hyperinflation of the lungs whilst resuscitating an asthmatic patient, what can you do to relieve air trapping
compress the chest whilst disconnecting the tracheal tube
