Resuscitation Flashcards
Name one trial evaluating endotracheal intubation vs. supraglottic airway device in patients. in cardiac arrest? Summarise findings
AIRWAYS-2 – RCT
* Multi-centre, cluster RCT, 9269 patients (but not all got SGA or ETT)
* SGA (supraglottic airway) associated with higher success initial ventilation
* SGA and ETT had similar rate of favourable neurological outcome (mRS 0-3) at 30 days
* No advanced airway better outcome than SGA or ETT (may be confounded by close to ED)
Causes of post-arrest hypotension
- Cardiogenic (can have element in post-arrest state)
- Hypovolaemia / Haemorrhage
- Obstructive shock: Tamponade / Pneumothorax (2o to CPR)
- SIRS response / distributive / anaphylaxis
Priorities of post-cardiac arrest care
Post resuscitations care
- Re-evaluate ABCDE
- 12-lead ECG
- Treat precipitating causes
- Aim for: SpO2 94-98%, normocapnoea and normoglycaemia
Clinical goals:
- Preventing further arrest
- Defining the underlying pathology
- Limit organ damage
- Predict non-survivors
ARC Pre-hospital Choking Algorithm
Uses for POCUS in the assessment of an adult patient in cardiac
arrest
- CARDIAC - Cardiac Output, and Cardiac Standstill
- CARDIAC - Tamponade
- LUNGS - Tension Pneumothorax
- ABDOMEN - Free Fluid in Abdomen - trauma and AAA
- CHEST - Aortic Dissection
- CARDIAC/LUNGS - DVT, PE
Mechanical CPR device: advantages and disadvantages
Advantages:
- Decreases staff utilisation
- Minimises interruptions to CPR (once attached)
- Effective and consistent chest compression
- Portability during patient transfers
Disadvantages:
- No mortality benefit
- De-skills providers
- Focuses on device attachment rather than effective CPR and early defibrillation
- Device displacement during compressions
- Blunt chest and abdominal trauma
- Device malfunction
ANZCOR recommendation regarding use of a mechanical CPR device
Does not suggest routine use
- Suggest that automated mechanical CPR devices are reasonable alternatives where
sustained high quality CPR are impractical or compromise provider safety.
Uses of waveform capnography in the resuscitation of a cardiac arrest resuscitation
- Adjunct for prognostication (Failure to achieve CO2 > 10 mmHg in 20 min is associated with
poor outcomes) - Identifies ROSC (by an increase in CO2 value)
- Confirms tracheal position and displacement
- Assess the quality of chest compressions
- Ventilation rate monitoring
Initial management and assessment of a newborn
- Clamp umbilicus
- Prevent heat loss, keep baby warm, warm towel dry under heat source
- Gentle stimulation (rubbing back, flicking soles of the feet)
- Assess APGAR score (initial cry, respiratory effort, heart rate, colour and tone)
- Ensure open airway
Newborn CPR parameters and indications
Initial face-mask (PPV) ventilation (Neopuff) at 40-60 brpm
If absent pulse, or HR <60 bpm (auscultation or palpated umbilicus) after 30 secs commence CPR
3:1 compressions-to-ventilation at 100 compressions/min
1/3rd chest depth, encircling technique
Cease when HR >60
Paediatric ALS timing and dosing
Reversible causes of cardiac arrest (adult + paediatric) - 4 H’s + 4 T’s
Hypoxia
Hypo/hyperthermia
Hypovolaemia
Hyper/hypokalaemia
Toxins
Thrombosis
Tension PTX
Tamponade
Focussed examination in decreased GCS
- Pupils – looking for toxidromes, or blown pupil of raised ICP
- Focal neuro signs c/w intracranial event
- Muscle compartments – exclude compartment syndrome due to lying on floor
- Skin examination for pressure areas
- Chest / lungs for aspiration from reduced LOC
Treatment of non-arrest hyperkalaemia
Resuscitation in rhabdomyolysis
IV fluid N/S – titrate to UO 1ml/kg/hr to manage rhabdo and prevent further renal failure
Risk of HyperK+, if present:
- IV Ca gluconate 10mL 10% (up to 60mL) for cardiac protection OR CaCl 5mL 10% (up to 30mL)
- IV HCO3 50-100mmol – K reduction
- IV insulin 10U / dextrose 50mL 50%
– Optional salbutamol for K reduction
Advantages and disadvantages of parental presence during paediatric resuscitation
Advantages:
- Allows parent to see all treatment being provided
- In case of unsuccessful resuscitation, allows initiation of grieving process
Disadvantages:
- Can worsen staff grief around events of highly emotive resuscitation
- Potential for interference with resuscitation from parents unless dedicated staff member caring for
parent
Hyperkalaemic arrest management
Protect the heart: give 10 mL calcium chloride 10% IV by rapid bolus injection or 30ml of
calcium gluconate
Shift potassium into cells: Give glucose/insulin: 10 units short-acting insulin and 25 g
glucose (50mL of 50%) IV over 15-30 mins. Monitor blood glucose.
Consider nebulised salbutamol 10-20mg
Give sodium bicarbonate: 50-100 mmol IV by rapid injection (if severe acidosis or renal
failure).
Remove potassium from body: Consider dialysis for hyperkalaemic cardiac arrest resistant
to medical treatment. Several dialysis modalities have been used safely and effectively in
cardiac arrest, but this may only be available in specialist centres.
Consider use of a
mechanical chest compression device if prolonged CPR is needed.
ERC guidelines
Medication treatment in premature labour
Betamethasone 11.4mg IM
Salbutamol 5mg neb
Tocolytics - If >32/40: Nifedipine 20mg orally, up to 3 doses Q 30min then TDS *Do not use with IV salbutamol, MgSO4, GTN, antihypertensives
- If <32/40: NSAIDs e.g indomethacin 50-100mg rectal/PO stat
Mg sulphate 2mg (up to 6mg) IV (do not use with nifedipine)
Indications for neonatal resuscitation
Poor tone
Lack of response to stimulation
HR < 100/min
Respiratory distress or lack of spontaneous respirations
Adrenaline in neonatal resuscitation
If HR <60/min after 60 seconds of chest compressions and 90 seconds of PPV
IV dose 0.1-0.3 mL/kg (10-30 µg/kg) 1:10,000
-0.25mL for < 30 weeks gestation
-0.5mL for 30-35 weeks
-1mL for > 35 weeks
ETT 0.5-1.0ml/kg (50-100 µg/kg) 1:10,000
- 1mL for < 30 weeks gestation
- 2mL for 30-35 weeks
- 3mL for > 35 weeks
Repeat every 2 mins, as required
Neonatal therapeutic hypothermia - parameters
Use in hypoxic ischaemic encephalopathy (HIE) - cooling may reduce the degree of brain injury. Commence within 6hrs after birth
Aim 33-34 degC for 72hrs from initiation and then rewarm gradually over 12-14 hours
Neonatal therapeutic hypothermia - indications/criteria
1) ≥ 35 weeks gestational age and more than 1.8kgs.
2) < 6hrs post birth
3) Evidence of asphyxia as defined by the presence of at least two of the following four criteria:
- Apgar ≤5 at 10 minutes or continued need for resuscitation with positive pressure ventilation +/- chest compressions at 10 minutes of age
- Any acute perinatal event that may result in HIE (i.e. abruption placenta, cord prolapse, severe foetal heart rate abnormality.).
- Cord pH <7.0 or base deficit of 12 or more within 60 minutes of birth
- If cord pH is not available, arterial pH <7.0 or BE>12 mmol/L within 60 minutes of birth (if available).
4) Not moribund and plans for full care
5) Clinically defined moderate or severe HIE (stage 2 or 3 based on modified Sarnat Classification)
6) Moderate to severely abnormal background activity on amplitude-integrated EEG (.i.e. discontinuous, burst suppression or low voltage +/-
7) At the neonatal consultant’s discretion to commence therapeutic cooling
Features predictive of survival in OOHCA
Witnessed arrest
Bystander CPR
Shockable rhythm (VF/VT)
ROSC in the field
Mild therapeutic hypothermia
PCI if STEMI present
Criteria for termination of resuscitation (TOR) in OOHCA
A general approach is to stop CPR after 20 minutes if there is no ROSC or viable cardiac rhythm re-established, and no reversible factors present that would potentially alter outcome.
From past Q:
No Shock has been administered *
No bystander CPR performed *
No ROSC has occurred
The OHCA was not witnessed by EMS
The OHCA was not witnessed by bystanders
Indications (relative) for prolonged resuscitation
- Young people with persistent VF until reversible factors have been fixed (see also Electrical storm) or therapeutic options exhausted
- Hypothermia (“not dead until warm and dead”)
- Asthma (need to correct dynamic hyperinflation)
- Toxicological arrest (full neurological recovery after >4 hours CPR is possible; asystole may be a direct drug effect that will recover in time)
- Thrombolytics given during CPR (should continue minimum 30 mins, up to 2 hours post-administration)
- Pregnancy, prior to resuscitative caesarean section or hysterotomy
ECMO contraindications
Absolute
- progressive non-recoverable cardiac disease (not transplant candidate)
- progressive and non-recoverable respiratory disease (irrespective of transplant status)
- chronic severe pulmonary hypertension
- advanced malignancy
- Graft-vs-Host disease
- >120kg
- unwitnessed cardiac arrest
Relative
- age > 75
- multi-trauma with multiple bleeding sites
- CPR > 60 minutes
- multi-organ failure
- CNS injury
VV ECMO pathology examples
- pneumonia
- ARDS
- acute GVHD (???)
- pulmonary contusion
- smoke inhalation
- status asthmaticus
- airway obstruction
- aspiration
- bridge to lung transplant
- drowning
VA ECMO pathology examples
- graft failure post heart or heart lung transplant
- non-ischaemic cardiogenic shock
- failure to wean post CPB
- bridge to LVAD
- drug OD
- sepsis
- PE
- cardiac or major vessel trauma
- massive pulmonary haemorrhage
- pulmonary trauma
- acute anaphylaxis
Paediatric anaphylaxis management
- Stop or remove offending agent, if able
- O2 via Hudson mask or non rebreather 100% O2, for sats >95%
- IM adrenaline 10mcg/kg into lateral thigh, repeat after 5mins if no improvement
- Adrenaline neb 1:1000 – 5 ml
- Stat NS bolus (10mls/kg) and repeat after 5mins - endpoint CRT <2, HR 140
- Hydrocortisone IV 5mg/kg
If inadequate response:
IV adrenaline infusion - 0.1-1 mcg/kg/min
Further IM adrenaline doses 10mcg/kg
Further NS 0.9% 10ml/kg bolus
General conditions suitable for ECMO therapy
- Conventional treatment resistant Respiratory failure – example Life threatening asthma
- Conventional treatment resistant cardiac failure – severe myocarditis, intractable dysrhythmias
- Life threatening poisoning – calcium channel blockers, beta-blockers
- Environmental – life threatening hypothermia
Hanging - Initial Management
Needs urgent intubation – anticipate difficult airway
Determine neuro status prior to RSI
Manual C spine immobilization to be considered
Neuroprotective measures
- Head up 30deg
- Collar off
- Oxygenation
- Avoid hypercarbia
- Sedation/paralysis
Hanging - prognostic factors
Down time; first aid/BLS rendered, initial vital signs and GCS
Cardiac arrest at scene
Comorbidities
Previous/current injuries
Estimated height of hanging fall; potential for C spine injury
Peri-intubation arrest: severe aortic stenosis
AS -> concentric LV hypertrophy + poorly compliant ventricle
Highly dependent on pre-load for adequate diastolic filling
Therefore: If you drop the pre-load (or the aortic end-diastolic pressure) – e.g. by vasodilation -> LV filling is poor & stroke volume low
Also dependent on diastolic filling time – so causing tachycardia is also bad (atrial fibrillation is very bad as highly dependent on atrial “kick” – normal heart = 20% of diastolic ventricular filling but in AS up to 40%)
Peri-intubation arrest: severe metabolic acidosis
Dependent on respiratory compensation++
Need to match their minute volume peri-intubation or the acidosis worsens rapidly
Leads to poor myocardial contractility, diminished catecholamine (vasopressor) responsiveness
Instead:
RSI with no apnoeic period (can use RR-matched NIV for pre-oxygenation), rapid intubation, match previous minute volume (TVxRR)
Peri-intubation arrest: severe asthma
Typically have maximal endogenous sympathetic outflow – this decreases with induction -> relative vasodilation
Positive pressure ventilation with inadequate expiratory time -> raised ITP, decreased VR etc
Consider pneumothorax
Rewarming techniques in hypothermia
Passive rewarming (removing wet clothes, place them in a warm, dry environment and cover with blankets)
- 0.5-2.0 degC/hr
- In stable, mild hypothermia only
Active external rewarming
- e.g. forced heated air system (Bair Hugger) most effective
- Warm/reflective blankets ineffective, only use if no other option
- Radiant heat for neonates
- 1-2degC/hr
- For moderate hypothermia
Active internal rewarming
- Less invasive:
- warmed humidified inhaled oxygen (40-45 degC); 1-1.5degC/hr
- Fluid/blood warmer (42degC); variable rewarming
- More invasive:
- Thoracic lovage (42 degC warm sterile saline into left pleural cavity); 3-6degC/hr
- Abdominal lovage; 2-3degC/hr
- Haemodialysis; 2-3degC/hr
- ECMO; most rapid 7-10degC/hr
ALS alterations in hypothermia
- Depending on rhythm spend up to one min checking for signs of life (controversial)
- Change in the adrenaline interval, may withhold until temperature >30, double duration between drug if temp is 30-35 degrees
- Intubate sooner, rather than later
- Chest may be stiff -makes compressions harder, consider using LUCAS
- Prolonged CPR is indicated
- Early call for ECMO CPR
Swiss Staging System in Hypothermia + severity
I – clearly conscious and shivering
II – impaired consciousness without shivering
III – unconscious
IV – not breathing
V – death due to irreversible hypothermia
mild: 32-35°C
moderate: 28-32°C
severe: < 28°C
Causes of raised CVP
Fluid overload
Pregnancy
IPPV
PEEP
Vasopressor
Pulmonary embolism
Right ventricular failure
Tamponade (may be normal if also hypovolaemic)
Tricuspid incompetence
Reasons to consider admission in paediatric anaphylaxis
Required >1 dose of adrenaline
* Severe asthma or history of biphasic reactions
* Possible continued allergen absorption
* Patient has difficulty responding to deterioration, no easy access to emergency care
* Presenting to ED in the evening or night
* Parental anxiety
* (Severe idiopathic anaphylaxis)- in this case likely nuts
* (slow response to adrenaline, requirement for inhaled beta agonists, initial hypotension)-
are all RFs for biphasic reactions
NIV - advantages and disadvantages
Advantages
- Reduced need for intubation by approx. 25%
- Reduced intubation-related complications e.g. pneumonia
- Provably improved likelihood of survival to discharge
- May reduce ICU LOS
- Enables treatment of patients who would otherwise not be suitable for intubation
Disadvantages
- Unable to be used in patients without spontaneous ventilation
- May not reduce the intubation rate in certain patient groups
- Impairs communication with patient
- Considered aerosol generating procedure, higher risk of airborne infection transmission
NIV contraindications
*unable to protect own airway
*uncooperative
*absent, weak, or agonal respiration
*excessive respiratory secretions
*maxillofacial fractures
*base of skull fractures
*recent upper airway surgery
*active vomiting
NIV complications
*facial skin necrosis
*conjunctivitis
*gastric dilation
-more common when PIP > 25mmHg and in small children
*aspiration
*pneumothorax
*hypotension
Indications for pre-hospital intubation in retrieval
- Head injury with LOC / anticipated LOC
- Profound shock
- Respiratory failure from chest injury
- High spinal cord injury – ineffective ventilation
- Severe pain / agitation
4 components of critical bleeding wound
Pulsatile bleeding
Expanding haematoma
Palpable thrill
Bruit on auscultation
Massive Transfusion Protocol target parameters
Definition of MTP
Replacement of >1 blood volume in 24 hours or >50% of blood volume in 4 hours (adult blood volume is approximately 70 mL/kg) ~4U PRBC
