Resuscitation in special circumstances Flashcards
What is the normal value of K+?
What is considered hyper-K+?
What is severe?
What is hypo-K?
What is severe?
3.5-5.0mmol/l
>5.5
>6.5
<3.5mmol/l
<2.5mmol/l
If pH decreases, what is likely to happen to k+
if pH increases, what is likely to happen to k+
k>
<k
How do recognise hyperkalaemia?
Tall peaked waves (greater than R wave)
Paraesthesia
Weakness
Merging s and t waves (Sine waves)
For mild elevation of k+, give? (5.0-5.9)
Resonium/polystyrene 15-30g
For moderate (without ECG changes), give? (6.0-6.4)
10 Units insulin + 25g dextrose over 15-30 mins, resonium
For severe hyperkalemia without ECG changes, give? (>or equal 6.5)
glucose/insulin/IV fluids/ventolin (10-20mg nebs), resonium, ?dialysis
For severe hyperkalemia, with ECG changes, give?
Calcium chloride (2-5min), glucose/insulin, ventolin, IVT, resonium, dialysis,
For cardiac arrest with hyperkalemia, give?
Rapid injection of: calcium, insulin/glucose, sodium bic.
What is hypokalaemia?
Severe?
What is some clinical signs?
<3.5mmol
<2.5mmol
weakness, cramps, constipation, rhabdo
What is the ECG sign of hypokalaemia?
U waves / T wave flattening, maybe AF
During cardiac arrest with hypokalaemia, what do you give?
MgSo4 (2g) and 5mmol K+
What is the max dose of k+?
20mmol/h
rapid infusion can be done where peri arrest (2mmol/min for 10 mins)
Familiarise yourself with p. 134
What is sepsis and what is the sepsis six?
SIRS or organ failure
lactate >4mmol/l
hypotension
oliguria
confusion
Sepsis six:
Give O2
Blood cultures
Give broad spectrum abx
Fluid resus (250-500ml bolus)
Measure lactate
Measure urine
For opioids, give?
naloxone (100mcg titration up to 800mcg)
For Benzos, give?
Flumazenil
For TCAs, (amitriptyline, -amine, doxepin), give?
Clinical signs?
When a child arrives in a shockable rhythm, assume?
Sodium bic (go for pH 7.45-7.55)
Hypotension, seizures, arrhythmias
Give lipid emulsion to who?
Those with local anaesthetic toxicity seen in cardiovascular / cerebral collapse
How much? 1.5ml/kg then 15ml/kg/hr (After 5 mins, give up to two more boluses with 5 mins between), double rate of infusion.
What treats malignant hyperthermia?
Dantrolene (eg. MDMA)
For asthma, give?
2x5mg ventolin with aim of SaO2 greater or equal to 92%
atrovent 500mcg
10mmol MgSo4
pred 50mg / hydrocort 100mg
consider iv ventolin if not possible to give airway
consider aminophylline in severe asthma
Half the doses for kids
What signs of tension pneumothorax are there?
subcutaneous emphysema
tracheal deviation
unilateral expansion of the chest wall
Anaphylaxis is met on what three criteria
- Sudden onset
- Airway, Breathing or Circulatory compromise
- Skin / mucosal changes (Sometimes not there)
There can also be gastro sx.
Adult anaphylaxis algo
What modifications should be done in cardiac arrest of pregnant woman?
Displace the uterus to the left (esp after 20 weeks)
Add left lateral tilt
If initial resusciation fails, you will need to deliver (preferably in 5 mins) - this helps the mother and a potential viable pregnancy (under 20 weeks not needed, however, needed if 24-25 weeks)
What is commotio cardis?
Actual or near cardiac arrest caused by blunt impact to the chest
In trauma, prolonged CPR (no response in 20 min), has what?
Poor survival and CPR needs to be stopped
In tension pneumothorax, where is the needle put for needle decompression?
2nd intercostal, mid clavicle
Or
5th intercostal mid axilla
When does a cardiac tamponade occur?
In cardiac surgery or trauma. The pericardial sac is filled with fluid under pressure.
Ultrasound can help diagnose
What is the treatment of cardiac tamponade?
In trauma, immediate thoracotomy is needed
What is submersion?
When the face is underwater -> Asphexia -> Cardiac arrest
Less than 10 min - good outcomes
More than 25 min - bad outcomes
What is immersion?
Head above water like with life vest -> Hypothermia
What is the role of hydrostatic pressure in drowning? (common in long immersion)
Hydrostatic pressure causes redistribution of fluid from periphery to central which is sensed by the body as hypervolemia that leads to diuresis, natriuresis, kaliuresis
When you get them out of the water, keep horizontal otherwise cardiovascular collapse can occur
When drowning, what rhythm comes first?
Bradycardia
What airway breathing modifications may be needed after drowning?
Early intubation
Peep may need to be as high as 15-20cm H2O but you start with 5-10.
What form of measurement should be used in hypothermia (less than 35 degrees celsius)? (severe is less than 28 degrees celsius)
Thermocouple tympanic
Low reading thermometer (using lower third of the oesophagus) - rectal and urinary are not recommended in severe hypothermia
What are some physiological principles of hypothermia that effects resucitation?
- Cellular oxygen consumption reduces by 6% for every 1 degree drop
- At 18 degrees celsius, the brain can tolerate circulatory arrest for 10x longer than at 37 degrees celsius
- Intermittent CPR is possible with min CPR and <5 mins of not
- Avalanche victims that have been under for >60 mins are unlikely to survive.
- Avalanche victims are unlikely to survive with potassium >8mmol/L
- Arrhythmias often revert to normal as the body warms
How long do you check for signs of life in a hypothermic patient?
1 min (Palpate, ECG, maybe Doppler)
Should you withhold ALS drugs in the hypothermic patient and when do you start giving?
Yes and give when core temperature is 30 degrees or greater
If VF persists after 3 shocks, then what in hypothermic patient?
Delay until temperature >28 degrees-30degrees
What are the stages and the general rewarming strategies?
Stage 1: 32-35 (shivering) - Blankets, foil, cap, let them exercise as more effective than shivering -> send to normal hospital
Stage 2-5: Chemical heat packs to the trunk -> Hospital with ECMO
In hospital rewarm with warm air ventilation and warmed fluids.
Passive rewarming can cause peripheral vasodilation.
In hypothermia, watch for afterdrop, which is?
A continuing fall in body temperate after removal from the cold environment
What is heat stroke?
> 40.6 degrees celsius + systemic inflammatory response, change in mental state and some organ dysfunction
Elderly are at greater risk
Signs and sx:
core temp
hot, dry skin or sweating
fatigue, headache, d+v, fainting
arrthymia / hypotension
ARDS
CNS like seizures / coma
liver / renal failure
rhabdo
What is the general principles of cooling?
Do it rapidly
Cool drinks
Fanning the undressed patient and spraying tepid water
Ice packs over axillae, groins, neck
Cool IV fluids
Intravascular cooling catheters
What causes death from electrical shock?
Tetany does not help (can’t let go)
Respiratory / Cardiac arrest
VF can be initiated by the electricity causes R on T
Tissue damage occurs
Hand to hand is the worst pathway
What should you treat / look out for in electric shock?
Burns
Early intubation
IV fluids / urine output
