Resus in special circumstances (ANZCOR) Flashcards
DIscuss resus of anaphylaxis
IF arrested due to anaphylaxis standard ALS treatment + large volumes of fluid resuscitation in the setting of distributive shock
Discuss ALS in the arrest asthma patient
Often a terminal event after a period of hypoxaemia
- linked to severe bronchospasm and mucous plugging leading to asphyxia
- cardiac arryhtmias due to hypoxia, stimulant drugs or electrolyte imbalance
- dynamic hyperinflation i.e autopeep - gradul build up of pressure occurs and reduces venous return and blodd pressure
- tension pneumothorax -often bilateral
Recommendations
- Follow standard resuscitation guidelines
- Ventilation will be difficult so ETT should be placed
- If dynamic hyperinflamtion of the lungs is suspected during CPR compression of the chest wall and/or period of apnoea (e.g disconnection of ETT after 2 minutes of CPR) may relieve gas trapping
Discuss ALS in the arrested avalanche patient
Avlanache victims are not likley to survive when they are
- buried >35 minutes and in cardiac arrest with an obstructed airway on extrication
- buried initially and in cardiac arrest with an obstructed airway on extrication and an intial core temp of <32
- buried initially and in cardiac arrest on extrication with an initial serum potassium of >12mmol
Recommendations
-full resus measures inclduing ECMO rewarming when aviable are indicated for all avalanche victoms who do not show evidence of unsurvivable injury
Discuss ALS in the post cardiac surgery patient
After major cardiac surgery arrest is realtively common in the immediate post op phase. THe main causes of arrest post cardiac surgery include
- cardiac tamponade
- MI
- haemorrhage causing hypovolaemic shock
- disconnection of the pacing system in a pacing dependant patient
- tension pneumothorax
- electrolyte disturbance
Reccomendations
- The use of 3 stacked shocks may be considered any time in the immediate post op period for cardiac arrest due to shockable rhythms due to potential harm of chest compression but only if the defib is immediately available (first shock wihtin 20 seconds)
- In the event of brady-asystolic cardiac arrest after cardiac surgery where epicardial wires have been previously attached these wires should be sued to attempt to pace the heart
- Opening the chest after recent cardiac surgery allows visualisation of or treatment of cardiac tamponade, visualisation of problems, direct cardiac compressions and facilitates institution of bypass if required. Should be considered if staff present qualified
- Chest compression should not be wihthled while preparing for emegent re-sternotomy
- ECHO is helpful for diagnosis
Discuss ALS in the setting of PCI
Recommednations
-THere is insufficient data to support or refute the use of mechanical chest compression, cough CPR or emergency bypass to imrpvoe outcome of cardiac arrest during PCI
Discuss ALS in the setting pericardial tamponade (non traumatic)
- pericardiocentesis guided by ultrasound should be considered for treatment of cardiac arrest associated with suspected cardiac tamponade while non image guided pericardiocentesis is an acceptable alternative only if ECHO not available
- Placement of a pericardial drain may be beneficial and may obviate the need for subsequent OT - ED thoractomy and pericardiotomy can be considered for use in the treatment of non traumatic cardiac arrest when pericardiocentesis is unsuccessful in relieving cardiac tamponade
- Fluid resus as needed
Discuss pericardial tamponade in traumatic arrest
- Ideal is surgical management of pericardial tamponade in theatre
- ED thoracotomy and pericardiotomy should be considered as an accpetable alternative to operating room thoracotomy and pericardiotomy for treatment of traumatic cardiac arrest associated with tamponade
If nether of the above are possible pericardiocentesis should be attempted
Discuss cardiac arrest and ALS in pregnancy
Most common cause of arrest in the pregnant patient are
- cardiac disease
- pulmonary thrombo-embolism
- haemorrahge
- sepsis
- hypertensive disorders of prenancy
- poisoning and self harm
- amniotic fluid embolism
Recommendations
- Summon help immediately -including O&G and neonatologist if available
- Manually displace the uterus to the left to remove caval compression Add left lateral tilt if feasible - aim for 15-30 degrees - angle needs to allow for high quality CPR
- Consider preparation for emergency caesarean section as the foetus will need to be delivered if initial resus efforts fail - decision within 4 minutes of arrest
Discuss ALS in PE
Fibrinolytic therapy may be considered when pulmonary thromboemobolism is suspected as the cause of the cardiac arrest
If fibrinolytic drug is given in these circumstances to allow time for optimal effect CPR should be performed for at least an additional 30 minutes before termiantion of resus attempts. Consideration should be given to performing 60-90 minutes
Discuss the use of three stacked shock
A sequence of 3 stacked shocks can be considered patients with a perfusing rhythm who develop a shockable rhythm where the setting is
- a witnessed and monitored setting and
- the defib is immediately available (first shock able to be delivered within 20 seconds)
- the time required for rhythm recognition and for recharging the defib is short
If not response to 3rd shock CPR should be immediatly started and normal ALS resumed
Discuss TOX alteration to ALS
Benzo
- nil change
- flumazenil during cardiac arrest is not recommended
Beta blocker
-standard
Ca Channel
-Standard
CO
-Patient who develop arrest due to CO rarely survive to hospital discharge even if return of spontaneous circulation is achieved however hyperbaric o2 therapy
may be considered in these patient as it may reduce the risk of developing persistant or delayed neurology
-risk of transported critcally ill patient post arrest to hyperbarics are high and need to be weighed against potential beneifit
Cocaine/amphetaimes
-standard
Cyanide
- Should recieve antidote hydroxocobalamin 5g with repeat dosing up to 15 g
Dig arrest
-digifab
LA
-insufficient clinical evidence to advise any change to cardiac arrest resus algorithms - however animal stuides and acse reports suggest the benefit of intralipid
opiates
- standard
- naloxone offers no beneift
TCA
- There is insufficient evidence to suggest any change to cardiac arrest resuscitation treatment algorithms for patients with cardiac arrest or cardiotoxicity caused by tricyclic antidepresants.
- since sodium bicarb bolus is the mainstay of therapy in the setting of TCA cardaic conduction abnormalities it should be considered during arrest
DIscuss alteration to ALS in trauma
Common causes of cardiac arrest should be sort and treated as a priority
- hypovolaemia
- tension
- tamponade
1) Prearrest : stop bleeding as prioty – attention to A and B should occur once bleeding has been ceased
2) airway - should be secured with attentiont to potential for c-spine injury - inline stablisation
- A patient in cardiac arrest due to trauma should ahve the airway opened as quickly as possible while not delaying blood volume expansion and relief of possible tension pneumo
- front of neck be required due to traumatic alteration in anaotmy
3) Iv access should be obtained as soon as possible.
- Peripheral access may be impossible in cardiac arrest due to exsanguination
- CVC can be attempted
- IO access (in adults IO in the sternum or humeral head ahcieve more rapid fluid admin than those in the medial proximal tibia)
- Initial warmed 20ml/kg of crystaolid bolus or blood (ideal) in exsanguinating haemorrahge this should be a 1:1 or 1:2 PRBC and FFP - or rotem guided
- Admin of large volumes of blood will cause a drop in ionised calicum necessitating replacement, monitoring of K
4) chest decompression
- all patient with traumatic arrest not responding to fluid resus and airway opening should have decompression
- finger thoracostomy is the preferred method – if decompressing should alwasy intubate due to the risk of air etnering the pleura space
5) pericardiocentesis
- the commonest cause of pericardial tamponade due to trauma is penetrating injury or wound to the myocardium which will require surgical intervention via thoracotomy.
- Needle pericardiocentesis is almost never the optimal means of decompression in traumatic pericardial tamponade - does not address myocardial injury and pericardial blood is often clotted
6) resuscitiave thoracotomy
- release tension penumohtorax or cardiac tamponade
- allow direct control of intrarthoracic haemorrahge
- allow cross clamping the descending aorta (stop blood loss below the ddiaphrgam and improve brain and cardiac perfusion
- permit open cardiac compression and defibrillation
Discuss ALS in crush syndrome
As per trauma ALS above
special attention to hyperkalaemic arrest with urgent treatment with K >6.5, ECG changes or a sine wave
-5-10ml 10% calcium chloride or 10-20 mls 10% gluconate
-Actrapid 10 units +50mls 50% dextrose
-bicarb 1mmol/kg IV
Discuss chest compression, adrenlaine and defib in trauma arrest
Chest compression
- an exsanguianted patient theoretically derives littel benefit from external cardiac compressions until blood volume is restored to a minimally sufficient quantity.
- Chest compression may exacerbate haemorrahge and cardiac tamponade and PPV may further reduce critically low venous return
- No evidence for benefit however no evidence for clear harm as such CPR should be commenced as a secondary priority after airway, commencement of restoration of ciruclating blood voluem and decompression of the chest
- If any indication for resuscitive thoracotomy internal cardiac compression is prefered
Adrenaline
-ANZCOR does not recommend adrenaline for patients in traumatic arrest until haemorrahge controle, opening of airway and commencement of restoration of circulating blood vulme and decompression have been addressed
Defib
Secondary as above
Discuss transport of traumatic arrest patients
Several potentially effective intervention may only avialable in the hosptial setting. Speef of transport should be prioritised over time taken performing prehospital intervention.
