Resuscitation in special situations M. Grochová I.KAIM, UPJŠ LF a UNLP, Košice.
Special Resuscitation Situations
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Transcript of Special Resuscitation Situations
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Special Resuscitation Situations
Presented by :Abdulgadir F. Bugdadi
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SPECIAL RESUSCITATION SITUATIONS
1. To understand the unique considerations involved in the common special resuscitation situations.
2. To be able to modify resuscitation efforts for special situations.
Objectives
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SPECIAL RESUSCITATION SITUATIONS
• Near Drowning.• Hypothermia.• Trauma.• Electrical shock.
Objectives
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NEAR DROWNING
• Drowning : Is usually defined as death from asphyxia within 24 hours of submersion in water.
• Near drowning :Refers to survival (even if temporary) beyond 24 hours after a submersion episode.
Definitions
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NEAR DROWNING
• 60,000-80,000 near drownings/year.• 6,000-9,000 deaths/year.• 3rd leading cause accidental death.• Peak incidence in teenagers and children
under 4 years.
Epidemiology in U.S.A.
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Effects
1.CNS effects.
2.pulmonary effects.
3.CVS effects.
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NEAR DROWNING
• Spinal cord injury (diving)• Air embolism or “the bends” (SCUBA)• Hypothermia
Possible Associated Injuries
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NEAR DROWNING
• Alcohol or other drug ingestion.• Hypoglycemia.• Seizures.• Cardiac disease, dysrhythmias, and
syncope.• Suicide, homicide, or child abuse.
Possible underlying causes
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NEAR DROWNING
• Rescuer safety.• Reach and remove the victim from water.• Protect cervical spine if trauma is suspected.• Start CPR.
Pre-hospital Resuscitation
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NEAR DROWNING
• Remove particulate matter via finger sweep.• Heimlich maneuver ONLY for particulate matter or
foreign body.
Pre-hospital Resuscitation (cont.)
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NEAR DROWNING
• Note ;1. Most important critical goal is correction of
hypoxia and acidosis.2. Most acidosis is restored after correction of
volume depletion and oxygenation.3. Hypothermia may also be present and
exacerbate bradycardia, acidosis, and hypoxemia.
Emergency Department Management
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Emergency Department Management (Cont.)
• Continue CPR (if needed)
• Intubation and mechanical ventilation (if indicated).
• Rapid volume expansion.• Cardiac monitor.
• Rewarm if hypothermic.
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NEAR DROWNING
• Check CBC, BUN, electrolytes.• Arterial blood Gases.• Foley catheter.• N/G tube if unresponsive.
Additional Procedures
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NEAR DROWNING
• Survival possible with prolonged submersion in cold water – especially in children
• Best predictor – early awakening following resuscitation
Prognosis
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TRAUMATIC CARDIAC ARREST• Important concepts for traumatic patients :1. In any patient with trauma suspect cervical injury specially
with the mechanism of injury.2. In arrested patient with chest trauma, suspect cardiac
tamponade and tension pneumothorax.
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TRAUMATIC CARDIAC ARREST
As in any arrested patient begin management with
ABC
Initial Management
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TRAUMATIC CARDIAC ARREST
• Volume resuscitation – 2 liters of fluids through 2 large bore I.V. canula.
• Signs of tension pneumothorax.• Signs of cardiac tamponade.
Remember in a trauma patient
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TRAUMATIC CARDIAC ARREST
• Immediate thoracotomy.• Open chest CPR.
Penetrating Chest Injury
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ELECTRICUTION
• >90% caused by generated electricity.• Low-voltage deaths – home or workplace.• High-voltage deaths – 86% at workplace.
Epidemiology
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ELECTRICUTION
• Major factors– Magnitude of electrical current– Duration of exposure to current
• Minor factors– Type of current (AC worse than DC)– Resistance of skin and tissues (Results in
dissipation of energy in a form of heat).
Danger of Cardiac Arrest
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ELECTRICUTIONEffect of Current Intensity
< 1mA : Tingling
5-30mA: “Let go current”
40-50mA: Respiratory arrest
> 100mA: Ventricular fibrillation
> 10A: Prolonged apnea
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ELECTROCUTION
• Electricity travels along nerves and blood vessels• Burns are often full thickness; may extend to bone; may
require debridement, escharotomy, fasciotomy, or amputation.
Thermal Injury (Electrical burns)
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ELECTRICUTION
• Cervical spine or other bony fracture.
• Head injury.• Myoglobinuria.
Remember Secondary Injury
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ELECTRICUTION
• Massive DC counter shock.• Death in 30% of victims.• Nearly all deaths follow immediate arrest.
Lightning Injury
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ELECTRICUTION
• Turn off current.
• ABC’s of CPR.
• Protect cervical spine and treat injuries.
Management
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• IV fluid replacement for severe burns and myoglobinuria;1. Urine output of 100 ml/hour.2. Mannitol 25 g IV then 12.5 g/hr for 6 hours.3. sodium bicarbonate to alkalinize urine.
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• Surgical consultation.
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HYPOTHERMIA
• Definition: core body temperature <35oC.
• Incidence: children/elderly most susceptible.
Definition/incidence
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Classification
• Mild ; 32 – 35 °C.• Moderate ; 30 – 32 °C.
• Severe ; < 30 °C.
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• Warning :May be missed if thermometer does not read below 34.4oC.
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HYPOTHERMIA
• Immersion in cold water.• Cold weather exposure.• Impaired thermoregulation – elderly,
infants, drug or alcohol ingestion, diabetes, infection.
Common Clinical Situations
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HYPOTHERMIA
• Inhibits release of ADH – diuresis/dehydration.• Hematocrit and viscosity of blood increase.• Insulin release and peripheral utilization inhibited –
elevated blood sugar.
Physiological Consequences
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HYPOTHERMIA
• Shivering.• Tachycardia, hypertension,
hyperventilation.• Memory loss.• Poor judgment.
Clinical Features – Mild hypothermia.
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HYPOTHERMIA
• Bradycardia.• Arrhythmias.• Hypotension.• Altered level of
consciousness.• Rigidity.• Eventual VF or
asystole.
Clinical Features – Moderate to Severe hypothermia.
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HYPOTHERMIA
• Early recognition.• Concentrate on restoring normothermia.• Cold heart irritable – move patient gently, avoid
unnecessary manipulation or procedures.• Severely hypothermic heart may be unresponsive to drugs,
pacing, or defibrillation so postponed these till temperature > 30 °C.
Treatment Principles
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HYPOTHERMIA
• Intubate if indicated.• Antiarrhythmics usually unnecessary.• Treat hypoglycemia with D50W.• Treat volume depletion with N/S or L/R.
Treatment Principles (cont.)
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HYPOTHERMIA
• Minimize further heat loss ;1. Remove wet garments.2. Use blankets/sleeping bag.3. Warm rescuer can lie next to victim.4. Warm humidified oxygen.
• Transport cautiously and gently.
Pre-hospital Management
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HYPOTHERMIA
• Passive or active external rewarming ;1. Warm room.2. Warm blanket.3. Warm clothing.4. Warm I.V. fluids (43oC).
• Raise temperature 0.5-1.0oC per hour.• Prognosis good.
Management – Mild to Moderate (> 30oC)
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HYPOTHERMIA
Warning ;• Rapid external rewarming can cause vasodilation.
Rewarming Shock
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HYPOTHERMIA
1. Warm humidified oxygen (42-46oC).2. Warm I.V. fluids (43oC).3. Active rewarming methods ;
a. Peritoneal lavage with warmed fluid (43oC). b. Thoracic/pleural lavage.
• For arrest, open chest massage with mediastinal irrigation can be considered.
Management – Severe (< 30oC)
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• For dysrhythmia , Bretylum tosylate (only known to be effective).
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HYPOTHERMIA
• Must be individualized by the physician in charge of the resuscitation based on unique circumstances of each incident
Decision to Terminate Resuscitation
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END
Thank You
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PREGNANCY
• Maternal blood volume and cardiac output increase• Uterine blood flow increases from 2% to 20% of
cardiac output• Placenta is low resistance circuit – vasoconstrictors
may be harmful
Cardiovascular Changes in Mother
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PREGNANCY
• Arrhythmia• Congestive heart failure• Pulmonary embolism• Intracranial or hepatic hemorrhage
Precipitants of Cardiac Arrest
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PREGNANCY
• Supine position compresses aorta and inferior vena cava
• Rolling mother to left side may increase cardiac output by 25%
Supine Hypotension
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PREGNANCY
• Before onset of fetal viability – save mother’s life• Conventional CPR/ACLS as indicated
Management of Cardiac Arrest (<24 weeks’ gestation)
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PREGNANCY
• Use of epinephrine must be weighed against possibility of harm to fetus
• If 5-10 mins CPR/ACLS unsuccessful, check for fetal viability with stethoscope or ultrasound
• Perform open chest CPR 15 min• If no response in 15 min, do emergency caesarean
Management of Cardiac Arrest (>24 weeks’ gestation