Module 10: Resuscitation in special circumstances Flashcards
Special circumstances?
- Anaphylaxis
- Asthma
- Electrolye disturbances
Key points to remember when managing a patient with suspected anaphylaxis:
- ABCDE approach
- IM doses of 1 mg in 1 mL (1:1000) adrenaline
- Repeat after 5 minutes if needed
- IV fluids and bronchodilators as necessary
- ALS guidelines if cardiac arrest occurs
*Adult dose: 500 mcg
*Child dose: 300 mcg of
How is ‘anaphylaxis’ defined?
- Rapid onset of
- Life-threatening airway, breathing or circulation problems
- Usually associated with skin/mucosal changes
Key points to remember when managing a patient with suspected asthma:
- Call for senior help
- ABCDE approach
- Oxygen, nebulised ß2 agonists, steroids
- Consider: IV magnesium, IV salbutamol and IV fluids. Discuss the potential use of an IV aminophylline infusion with a senior colleague before starting that course of treatment.
NB: The patient will be difficult to ventilate because of bronchospasm - there is a high risk of gastric inflation with a bag-mask. Early tracheal intubation is desirable.
Management of hyperkalaemia in arrest
e.g. with an initial rhythm of asystole?
- Call for senior help
- ABCDE approach
- CPR
- Medical management:
1) Calcium chloride 10 mL 10% IV, rapid bolus injection
2) Sodium bicarbonate: 50 mmol IV, rapid injection
3) Glucose/insulin: 10 units short-acting insulin and 25 g glucose IV, rapid injection
-> Consider haemodialysis: an option for cardiac arrest induced by hyperkalaemia which is resistant to medical treatment.
What does calcium chloride IV do?
Stabilises the myocardial cell membrane
When to give sodium bicarb IV?
if severe acidosis or renal failure
Can you give salbutamol nebs in hyperkalemic arrest?
No - nebulisers cannot be easily administered during cardiac arrest - only use in pts with pulse
Management of hypovolaemic arrest in: haemorrhage
- ABCDE approach
- Call for help - alert surgical team
- Fluid infusion + control bleeding*
- Request and administer blood products.
- Transfer to theatres for surgical control of bleeding.
*Applying direct pressure
*Fixation of fractures
*Radiological embolisation.
Management of hypovolaemic arrest in: sepsis
- ABCDE approach
- Sepsis 6
3 in: fluids, antibiotics, oxygen
3 out: blood, urine, lactate
Steps 1-4 should be completed in the first 3 hours. Further treatment needs to be completed within 6 hours.
1. Measure Lactate
2. Take blood cultures
3. Broad-spectrum ABx
4. Initiate fluid resuscitation
- Measure Lactate
- Lactic acid is a product of anaerobic metabolism.
- Elevated lactate is not specific to sepsis, but does indicate circulatory compromise and can be used to predict outcome.
- High lactate which decreases with fluid challenges can be used to guide ongoing resuscitation
- Take blood cultures
- Prior to ABx
- One set of BCs plus fluid samples specific to source of presumed infection
- Broad-spectrum ABx
- Give ASAP in the first hour
- Initiate fluid resuscitation
- 30 mls kg-1 of crystalloid for hypotension or lac >4
Circulatory shock, from a combination of vasodialation and hypovolemia (due to leaky capillaries) is the most common cause of organ dysfunction in sepsis.
ECG TCA toxicity
tachycardia with broad QRS complexes
Management of poisoning
ABCDE approach
Specific treatments:
- Activated charcoal if poisoning ≤1h
- Consider 50 mmol L-1 of sodium bicarbonate
- Consider haemodialysis to remove specific poisons
- Consider IV lipid emulsion (Intralipid) for cardiac arrest 2º to local anaesthetic toxicity
- Further advise: TOXBASE®
Opioid toxicity.
Respiratory depression, pinpoint pupils and coma followed by respiratory arrest
Supportive care
Specific antidote: naloxone
Benzodiazepines: overdose
Loss of consciousness, respiratory depression and hypotension.
Specific antidote: Flumazenil
ONLY use for reversal of sedation caused by a single ingestion of a benzo, and when there is no history or risk of seizures.
Management of arrest in pregnancy
- Call for help – obstetrician, aneasthetist, Paediatrician.
- CPR in left lateral tilt to prevent aortocaval compression.
- Give intravenous fluid
early tracheal intubation/airway protection as there is a high risk of aspiration.
Key modifications to ALS for a pregnant patient.
- Early consideration of tracheal intubation/airway protection due to increased risks of airway compromise/ aspiration
- Lateral displacement of the uterus (> 20 weeks or if clinically obvious)
- If ≥20 weeks pregnant, and there is no ROSC within 5 minutes of arrest, deliver the fetus by perimortem CS/ hysterotomy.
