Hersheychapter 1

8/9/2019 Hersheychapter 1

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Chapter 1: EmergencyMedicineCardiopulmonary ResuscitationAdvanced Life SupportOffice EmergenciesMedical Emergencies (Cardiac Dysrhythmias)Summary of CPROther Medical EmergenciesShockBlood and Blood Components for Emergency Use


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EMERGENCY MEDICINECardiopulmonary Resuscitation

1. Rescue breathing: Adult victim

a. Check responsiveness: shake or tap gently and ask "ARE YOU OK ?"b. If unresponsive yell for helpc. Open the airway: head tilt/chin-lift to open airway, and check forobstruction. Remove if presentd. Check for breathing: if no breathing then give 4 quick breaths (Observechest rise)e. Check for pulse (Carotid) for 5-10 seconds: if .pulse is present but there isno breathing thenf. Start rescue breathing: inflate @1 breath every 5 seconds. Continue for 1minuteg. Reassessment: check pulse and breathing, if breathing then stop CPR. If

no breathing but pulse present, then just continue ventilations. If nobreathing and no pulse, then begin CPRh. Start chest compressions over sternum: using heel of hand withfingertips off sternum and with elbows straight; compress 181 /2 to 2inches @ 80 to 100/ minutei. Provide proper ventilations: give 2 breaths after 15 compressions ifworking alone or 1 breath to every 5 compressions when two rescuersare present

2. Rescue Breathing: Infant victima. Check responsivenessb. If unresponsive call for helpc. Open airway: if obstructed then cleard. Check for breathing: if no breathing then cover victim's mouth andnose with rescuer's mouth and give 4 puffs of air (Observe chest rise)e. Check for pulse (Brachial): if pulse present but no breathingf. Start rescue breathing: inflate @ 1 breath every 3 seconds, continue for 1minuteg. Reassessment: check pulse and breathing if victim is breathing then stop

CPR- if victim is not breathing and pulse present then continueventilations- if victim is not breathing and has no pulse then start chestcompressionsi. Infant chest compressions should incorporate 2-3 fingers on the sternumcentered on an imaginary line between the nipples, compressingvertically 1/2 to 1 inch at a rate of 100/minute ventilations occurring afterevery 5 compressions

Note* Do not perform a precordial thump in an unwitnessed event

Note* Do not perform a precordial thump in an unwitnessed event


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3. Rescue breathing: Child victima. All of the above holds true except that the rescuer feels for the carotidpulse compressions occurring one finger width above the substernal notchusing the heel of the hand at a compression rate of 80-100/ minute-

maintain cycles of 5 compressions to every 1 ventilation

Advanced Life Support1. Advanced cardiac life support: includes the use of drugs, defibrillation,intubation and military antishock trousers (MAST)- the basic protocol is asfollows:a. Begin basic CPR (Airway-Breathing-Circulation)b. Determine circumstances (Past history-current medications) c. Begin IV andintubated. Determine cardiac rhythmse. Determine blood gasesf. Begin appropriate drug therapy. These drugs include:

i. Atropine: decreases vagal tone to increase heart rate

used in sinus bradycardia/high degree AV block dosage- .5mg IV Q 15 minutes up to 2mg.

ii. Bretylium: used in V-fibrillation and V-tach when lidocaine and countershock fails dosage v-fib: 5-10gm/kg bolus Q 15 min to max 30mg/kg dosage v-tach: 5-10 mg/kg IV over 10 minutes, then 1 to 2 mg/min IV drip

iii. Calcium: should only be used to treat acute hyperkalemia, hypocalcemia, and

calcium channel blocker toxicity (there is no data showing itseffectiveness during CPR)

increases cardiac contractility and excitability

used in asystole

dosage: calcium chloride 2-4 mg/kg Q 10 minutes (Approx 500 mg)

used in pump failure

dosage: 2.5-1 Omicrograms/kg/min

iv. Dopamine:

alpha, beta, and delta agonist

used to support cardiac output, BP and renal perfusion in shockstates

dosage: start at 2-5 micrograms/kg/min, titrate to effect 20micrograms/kg/min

NOTE* Do not perform a precordial thump


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large dose has mostly alpha effectv. Epinephrine:

alpha and beta agonist, increases heart rate and contractility

used in asystole, V-fibrillation, and cardiac arrest

dosage: .5 to 1.0mg (5-10 ml of 1-10,000) IV Q 5 min

vi. Furosemide (Lasix):

loop diuretic and vasodilator

used for pulmonary edema and congestive heart failure dosage: starting dose is 0.5, mg/kg IV and total dose not to exceed 2.0 mg/kg IV

vii. Isoproterenol (Isuprel): pure beta agonist increases heart rate, contractility and consequently cardiac output used in asystole, symptomatic heart block and bradycardia dosage: 1 mg in 500 cc D5W to give a starting dose of 2 mcg/min, titrate

to effect (to achieve a heartrate of 60 beats/minute)

viii. Lidocaine (Xylocaine): decreases automaticity and raises v-fib threshold used to suppress PVC's, v-tach and v-fib

gm/kg 50-100gm bolus, then 2-4mg/min IV drip

ix. Procainamide (Pronestyl): decreases cardiac excitability, decreases automaticity of ectopic

pacemakers, and slows conduction used to suppress ventricular ectopics when lidocaine fails dosage: 100mg IV with a rate of 20mg/min until dysrhythmia disappears or

hypotension ensues, QRS complex is widened by 50%, or total of 1 gm ofdrug is injected

x. Propranolol (Inderal): beta blocker (to be used with caution in patients with COPD, diabetes and heart

failure used to control recurrent ventricular and atrial tachydysrhythmia dosage: 1 mg IV Q 5 minutes to 5 mg total (total dose not to exceed 0.1 mg/kg)

must administer slowly

xi. Sodium Bicarbonate:

used to counteract metabolic acidosis dosage is based on blood pH or empirically, 1 mEq/kg IV (50-100 mEq or 1-2

amps)

g. Cardioversion as necessary (Defibrillation) for ventricular fibrillation Procedure asfollows:1. Use paste or pads on skin


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ii. Charge defibrillator with SYNCHRONIZATION switch offiii. Place paddles as directed on the handles: one on the right uppersternum and the other on the left anterior axillary lineiv. Apply paddles with firm pressure (turn off oxygen)v. Shout," clear", make sure no one is touching the victim vi. Press both paddle

switches simultaneously to fire the unitvii. Repeat as necessary : Start at 200-300 joules- maximum output400 joules

Office Emergencies1. Syncope- Vasovagal reflex (Primary shock; fainting)a. Defined as transient loss of consciousness due to sudden release of thearterial vasomotor tone and temporary insufficiency of cerebral circulationb. Causes are sudden extreme fear or pain or the effect of severe injuryc. Differential diagnosis: epilepsy, hyperventilation, hysteria , carotid sinussyndrome, cardiac arrhythmia, drugs and orthostatic hypotension d. Signs

and symptoms: pallor, sweating, slow pulse, yawning and marked transienthypotensione. Treatment is supportive: recumbent position, take B.P., pulse, spirits ofammonia, O2 and drugs (Atropine/Ephedrine) only if previous treatment fails

2. Local Anesthetic Toxicitya. Causes are too much volume or too concentrated solution; extremerapid absorptionb. Reactions- rapid and delayed; with cerebral stimulation and/or depression;respiratory stimulation; cardiac depression; hypotension; shockc. Signs and Symptoms: apprehension , nausea, BP elevation, convulsions,

perioral tingling, or most seriously, post-ictal depression, respiratory depression,hypotension respiratory and cardiac arrestd. Treatment- mental changes/watch patient, respiratory depression/O2,hypotension/ vasopressors i.e. Ephedrine 20 mg IM convulsions/Valium 5mg IV, and CPR if necessary

3. Anaphylactic Reactionsa. These are toxic reactions that occur in persons who are allergic byheredity or who have become sensitized to a given drug or therapeuticagent after previous administration. Respiratory obstruction is thecause of deathb. Reactions- anaphylactic shock, angioneurotic edema (swelling of softtissues of throat), asthma with acute bronchospasm, urticaria and pruritusc. Signs and symptoms of anaphylactic shock - skin wheals, itching,angioedema, laryngeal edema, bronchospasm (wheezing) dyspnea,

Note* Ephedrine raises BP and causes tachycardia while Vasoxyl raises BPwithout tachycardia (due to the alpha effect)


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cyanosis, apnea, vomiting, hypotension, cardiorespiratory collapse anddeathd. Treatment of anaphylactic shock (must be immediate)- .5cc epinephrine IVor IM (children 0.01 mg/kg), tourniquet and .25cc epinephrine at injection site,O2 & airway, Solu-cortef 200 mg IV and CPR if necessary

4. Allergic Reactions:a. End organ response of the skinb. Symptoms are hives, (urticaria), bronchial asthma, and G.I. upset c.Treatment: 25-50 mg IM Benadryl- if severe then treat as if anaphylacticreaction- if tongue swelling use epinephrine

5. Acute asthmatic attack:a. This is an intermittent airway obstruction, which is reversible- can beacute and severe leading to respiratory failureb. Causes- allergies, irritants, infections, extreme cold, drugs and emotionc. Signs and symptoms- recurrent attacks of wheezing dyspnea and coughd. Treatment- reassurance, rest, O2, drug therapy (epinephrine .5cc 1:1000subQ every 20 min up to 3 doses - if no relief then aminophylline 5-6mg/kg over 20 minutes, hydrocortisone 100mg)

6. Seizures (major convulsions):a. Defined as convulsive disorders characterized by abrupt transientsymptoms of motor sensory, psychic, or autonomic nature, frequentlyassociated with change in consciousness. Changes thought to besecondary to sudden transient alterations in brain function associatedwith excessive rapid electrical discharge in the gray matter.


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b. Causes: idiopathic, pathological states (brain tumor, CVA, head trauma),local anesthetic toxicity, and intoxicationsc. Signs and symptoms in grand mal (major epilepsy)- aura, severegeneralized clonic, convulsive body movements followed by a period offlaccid coma, then a period of sleep (post-ictal depression)- with status

epilepticus: recurrent and severe seizures with short or no intervalsbetween seizuresd. Treatment- except in status epilepticus no specific treatment is necessaryexcept to protect patients from hurting themselves- in status epilepticusstart with Valium, then Dilantin, then phenobarbital prn

7. Hypertension:a. Defined as persistent elevated BP above normal for the patient(borderline hypertension BP>140/90)b. Signs and symptoms- headache, convulsions, visual changes, with acuterise in BP

c. Treatment- start supportive therapy and reduce BP with sublingualnifedipine 10mg (Procardia) then send for medical evaluation

8. Insulin Shock (hypoglycemia):a. Defined as low blood sugar that occurs when a diabetic who has takeninsulin, fails to ingest food or engages in too strenuous exerciseb. Treatment- if conscious and able to swallow then give orange juice- ifunconscious then give IV glucose 20 to 50 ml. of 50% solution

Medical Emergencies (Cardiac Dysrhythmias)1. Myocardial Infarct (uncomplicated): Characterized on EKG by big Q wavesa. Monitor EKGb.100% O2 with nasal cannulac. Start IV lines with D5Wd. Sublingual nitroglycerin can helpe. Relieve pain with morphine sulfatef. Do blood gases/pH/electrolytesg. Consider use of prophylactic lidocaine

2. Asystole: Characterized by a flat line on the EKGa. Use basic CPR, begin IV, intubateb. Give epinephrine and bicarbonatec. If ineffective give calcium chlorided. If ineffective give atropinee. If ineffective give isoproterenol'f. If ineffective repeat steps b-e and as a last resort can give epinephrine

NOTE* If the diabetic patient is seen when unconscious, and if the diagnosis ofcoma or insulin reaction is in doubt, give 50% glucose IV- this will

overcome insulin reaction but will not generally harm patient indiabetic acidosis


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intracardially or using a transvenous or external pacemaker

3. Ventricular Fibrillation: The gravest of all arrhythmias characterized byirregular and uncoordinated movements of the ventriclesa. Use basic CPR, begin IV's, intubate (if unconscious)

b. Use precordial thump only if witnessed arrest then defibrillate with 200-300 joules- repeat prnc. If unwitnessed event do not use countershock: first start with epinephrineand bicarbonated. If no response give epinephrine and bicarbonatee. Defibrillate at 400 joulesf. Use lidocaine or procainamideg. If no response use bretyliumh. After successful conversion use lidocaine drip

4. Ventricular Tachycardia:

a. Begin lidocaineb. Use CPR if no pulse/O2/ IV's (and unconscious)c. Use precordial thump if witnessed eventd. Consider cardioversion and procainamide or bretylium if lidocaineineffective

5. Third degree AV heart block:a. Use atropine .5mg IV followed by isoproterenol prn b. Pacemaker6. Premature ventricular contractions (PVC's): (frequent) May lead to V-ib(if untreated)


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a. Lidocaine 100mg IV bolus followed by lidocaine IV drip

Wolff-Parkinson-White syndrome:

a. Characterized by a short P-R interval and prolonged QRS time. There is a40% incidence of episodes of paroxysmal tachycardia, atrial fibrillation andatrial flutter, as well as the possibility of sudden death. Can occur in healthyindividualsb. Treatment: Digitalis, quinidine, propranolol, artrial pacing

Summary of Cardiopulmonary Resuscitation1. Establish the diagnosis: Apnea, no pulse, absence of heart sounds,absence of responsiveness, ashen gray color2. Summon help: Time is critical; you only have 4-6 minutes to reestablishventilation

3. Do not thump the patient's chest (not part of CPR any more)4. Check for absence of breathing first. Displace the mandible forward, andclear the airway manually, then give 2 rapid respirations5. Place support under patient's back and start mouth-to-mouth breathingand external cardiac compression (5:1 with two rescuer sequence or 15:2solo). Depress the sternum 4-5 cm (1.5-2 inches)6. Insert ET tube to ventilate with 100% oxygen (only by experiencedpersonnel)7. Start IV infusion by needle or cutdown. Administer epinephrine andsodium bicarbonate and repeat bicarbonate injections until arterial bloodgases and pH results are known

8. Monitor EKGa. If V-fib: Closed chest compression, epinephrine, sodium bicarbonate,defibrillate (if not effective repeat countershock)9. Inject epinephrine, and if defibrillation not successful, repeat10. Following restoration of heart function inject lidocaine for excessiveventricular irritability11. If asystole is present, heart function may resume following myocardialoxygenation by ventilation and external cardiac compression12. If asystole persists inject epinephrine and sodium bicarbonate., calciumchloride and isoproterenol prn13. If electromechanical dissociation is present take therapeutic

steps as with asystole14. Corticosteroids may be used to decrease cerebral edema15. Postcardiac arrest therapy includes corticosteroids, diuretics,hypothermia, and hyperventilation. Monitor arterial blood gases, BP, EKG,CVP (central venous pressure), urine, electrolytes, and chest x-ray

Other Medical Emergencies1. Narcotics Overdose:a. Give Naloxone (0.2-0.4 mg IV or IM/ in children .01 mg/kg: repeat Q 5


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IVAC)e. Prior to Heparinization do PTT- during treatment adjust to keep PTT 2Xnormalf. If thrombophlebitis present treat with elevation and moist heat (may needantibiotics)

6. Hypertensive Emergencies:

Hypertensive encephalopathy

Malignant Hypertension

Accelerated Hypertension

Hypertensive Crisisa. Diagnosis of Hypertensive encephalopathy or accelerated malignanthypertension is a clinical one and demands immediate aggressive therapyto lower BPb. Treatment initially should be Diazoxide (Hyperstat) 300mg by rapid IVbolus or can give hydralazine (should give Furosemide simultaneously-

prevents fluid retention)

7. Malignant Hyperthermia (also see Chapter Anesthesia, Section: OtherMedical Complications of Anesthesia):

a. With exposure to inhaled anesthetic agent the patient exhibitsfasciculations and increased muscle tone, with jaw clenching during the

induction of anesthesia a typical early sign and body muscles becomingrigid and excessive body heat producedb. Anesthesia must be discontinuedc. Patient must be cooledd. INTRAVENOUS DANTROLENE SODIUM HAS A THERAPEUTIC EFFECTe. If suspicious of malignant hyperthermia pre-op do CPK LEVEL- THISLEVEL IS ELEVATED IN 79% OF THE PATIENTS WITH MALIGNANTHYPERTHERMIAf. Early signs:i. Tachycardiaii. Tachypnea

iii. Unstable BPiv. Arrhythmiasv. Dark blood in the surgical fieldvi. Cyanotic mottling of the skinvii. Profuse sweatingviii. Feverix. Fasciculationsg. Suggested treatment regimen:i. Stop anesthesia

Defined as a catastrophic reaction to general anesthesia An inherited traitIncidence of 1 in 20,000


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ii. Hyperventilate with 100% oxygen (8-10 liters/minute)iii. Start Dantrolene sodium IV as soon as possible (starting dose 1mg/kg up to a maximum cumulative dose of 10 mg/kg by rapid infusion)iv. Start Procainamide IV if required for arrhythmiasv. Initiate cooling

-IV iced saline (not Ringer's) surface cooling with ice and hypothermia blanket

Lavage of stomach, bladder and rectumvi. Correct acidosis and hyperkalemia with sodium bicarbonatevii. Monitor EKG, temp, urinary output, electrolytes, arterial pressure andblood gases, pH, and electrolytesviii. Maintain urine output of at least 2 ml/kg/hr: administer Mannitol andFurosemide (if necessary)ix. If necessary administer Insulin to provide energy to the cells andnormalize the pHx. Administer oral Dantrolene for 1-3 days after the crisis

NOTE* Avoid amide local anesthetics if a patient has a history of malignanthyperthermia reactionNOTE* Malignant hyperthermia is most frequently seen when halothane andsuccinylcholine are used togetherShockThe mechanism of shock is poorly understood, however, this phenomenonresults in inadequate tissue perfusion with accompanying cellular injuryand metabolic disturbances. Shock cannot be defined but it can be classifiedby etiologic means1. General clinical presentation:

a. Tachycardiab. Hypotensionc. Low tension pulse (thready pulse)d. Collapsed superficial peripheral veinse. Oliguriaf. Hypothermiag. Metabolic acidosis

2. Etiology:a. Hypovolemic: Caused by a reduction in circulating blood as a result oftraumatic injury, GI bleed, crush injuries, burns, massive diarrhea, and

peritonitisb. Septic: Caused by infections that produce an endotoxic or exotoxicreaction. Most common gram (-)'s are E. coli, Proteus group, Pseudomonas,Klebsiella and meningococci. Less often involved are gram (+)'s such asstaphylococci, streptococci, and clostridiac. Neurogenic: Severe injury to the spinal cord or brain can cause a loss invasomotor tone resulting in vasodilation and hypotension from the loss ofperipheral vascular resistance. Also psychogenic factors such as the sight ofblood or surgery can produce shock


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d. Cardiogenic: Produced by hypotension arising from inadequate cardiacoutput as a result of serious arrhythmias, tamponade, Ml, CHF, andpulmonary embolisme. Metabolic: Caused by alterations in the fluid electrolyte balance as aresult of systemic diseases such as diabetic acidosis, renal failure, or chronic

respiratory diseasesf. Anaphylactic: Occurs following the injection of heterologous sera,penicillin and other medications

3. Treatment of shock:a. Assess the physical status of the patientb. Lie the patient down and keep him/her warmc. Maintain airway administering oxygen at 8-10 liters/minute. If patientunable to breath on their own use Ambu bag (use- CPR if necessary)d. IV fluid replacement to avoid dehydration. Do not use lactate solutions

e. Vasopressor drugs can be used providing there is sufficient blood volume to beeffective (the mechanism and etiology of shock dictates the specific drug)f. Lab studies should be instituted such as pH, pO2, pCO2, serum electrolytes,BUN, lactic and pyruvic acids, and hematocritg. Measure the urine volume (normally it should be above 30 ml/hourpersistent oliguria below 25 ml/hr for more than 2 hours may cause renal cellnecrosis)g. If infection is suspected cultures should be performed, and appropriateantibiotics initiatedh. For allergic/anaphylactic reactions treatment as mentioned above shouldbe instituted

NOTE* Expanding the intravascular volume is the primary goal in the initialtreatment of hypovolemic shock


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Blood and Blood Components for EmergencyUse (also see Ch. 11 Fluid Management)1. Red Blood Cellsa. Description:i. Available as "packed RBCs" of 250 cc, split units of 125 cc, or quadpacks for newborns

ii. Anticoagulants are used to prevent clotting and a small residual amount ofplasma is presentiii. Units can be prepared and combined with special filters to preventfebrile reactions (leukocyte poor)iv. Unit can be washed to prevent allergic reactions (washed RBC's)v. One unit can raise the hematocrit by 3% or Hb by 1 gm.b. Compatibility:i. The unit must be ABO compatible, but Rh compatibility not required butpreferredii. Rh positive blood can be given to patients especially those over 50 yearsof age, who are expected to use multiple units (10% will develop Rh

antibodies 3-4 months later, and by this time the transfused Rh+ cellshave been cleared)iii. When Rh- units are in short supply they should be saved for women ofchild bearing agec. Alternatives:i. Autologous transfusions: patients can donate up to 3 units of blood prior tosurgery and have these units available if subsequent bleeding occurs duringthe procedure (the safest)ii. Directed transfusions: Patients can elect to have friends and relatives donateblood for upcoming surgeryiii. Perioperative cell salvage: Patients may elect in certain operative procedures

to have blood lost during surgery, recollected, filtered and transfused (sterileorthopedic procedures and abdominal aortic aneurysms)c. Indications for RBC's:i. Hypovolemia due to acute blood loss and associated with one or more ofthe following: Acute bleeding with an actual or anticipated blood loss of 750 ml or

more Systolic blood pressure 100)

NOTE* Patients with a history or suspicion of penicillin allergy may be testedas follows: Dilute penicillin G to a concentration of 1,000 units per ml andplace 1 drop on a skin scratch on the forearm. If the test is positive awheal will be seen within 15-20 minutes. If the test is negative, inject asmall amount of this solution intradermally to double check. This

indicates the decreased probability of anaphylactic response but does nottotally rule out an allergic state. Keep a "shock kit" immediately availablebecause even a test can initiate anaphylactic shock. Also the risk oftesting is that patients may become iatrogenically sensitized to future doses


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Hct < 30% and documentation of a fall of 5% or more within 24 hours or10% or more within one week

Central venous pressure < 3 cm/H20ii. Chronic anemia: Uncomplicated: Hct < 24 or Hgb < 8 mg (and not due to acute blood loss)

with anemia syndrome Complicated: Hct < 30% or Hgb < 10% with complications affecting

oxygenation (cardiac or respiratory insufficiency) Anesthesia pre-op: Hct < 30% or Hgb < 10mgiii. Hemodialysis

d. Adverse reactions:i. Infectious reactions:

AIDS: Risk is 1:20,000 to 1:40,000 for each unit transfused Hepatitis (B C): less than 1

MVii. Noninfectious reactions

Febrile: fever reaction most common. This reaction involving circulatingantibodies in the recipient which react to HLA antigens in infusedgranulocytes

Allergic: associated with circulating serum antibodies within the

recipient to infused immunoglobulins within the small amount of residualplasma of the red cell unit (hives, serum sickness, anaphylaxis)

Hemolytic: is a result of circulating naturally occurring antibodies in therecipient to antigens on the RBC's causing cell lysis

Graft vs. host disease: engraftment and multiplication of donor blood cellsin an immunosuppressed recipient are possible, and here, immunocompetentlymphocytes become engrafted and cannot be rejected

2. Platelets:a. Description: Are a concentrate separated from a single donor byplasmapheresis from whole blood containing 5.5 x 1011 platelets in 200

300 cc of plasma and anticoagulant, and can be expected to raise the adultplatelets count by 60-80,000 unless platelet antibodies are presentb. Compatibility: ABO compatibility is preferred, but in emergencies or shortsupply any ABO group can be used (Rh is not a factor).c. Alternatives: Random donor platelets are obtained from a single unit ofwhole blood and contain 1 /10 the number of platelets in 30-50 cc, and 6-10 units are standard suggested therapyd. Indications:L Prophylaxis:

NOTE* RBC's must be used within 4 hours after removal from the refrigeratorand must return within 20 minutes to the Blood Bank if not used. Warmingcan result in bacterial proliferation if allowed to warm to room temperaturebefore returning to refrigeration


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Platelet count < 20,000/mm3 or anticipated drop below 20,000 in the

next 24 hours Platelet count < 80,000 with surgery anticipated or in the acute post-op

period A platelet function defect with surgery anticipated or in the acute post-op

periodi. Bleeding: latelet count < 20,000/mm3

latelet function defect (known or suspected)e. Adverse reactions: Same risks as RBC's

3. Cryoprecipitate:a. Description: Prepared by thawing fresh frozen plasma at 4C andrecovering the cold precipitate. Each bag of 'Cryo' contains 90 or more FactorVIII units and at least 150 mg of fibrinogen in less than 15 ml of plasmab. Compatibility: ABO compatibility is preferred but not required in

emergency situationsc. Alternatives: Fresh frozen plasma can be used if there are associateddeficiencies of individual coagulation factors, massive blood transfusion, orwhen cryoprecipitate is in short supplyd. Indications:i. Von Willebrand's Diseaseii. Hypofibrinogenemia associated with bleeding or surgery (perioperative)iii. Dysfibrinogenemia associated with bleeding or surgeryiv. Uremia associated with bleedingv. Factor XIII deficiencye. Adverse reactions: Same as with RBC's

4. Fresh Frozen Plasma:a.Description: Is the anticoagulated clear liquid portion of blood that isseparated and frozen within a few hours of Whole Blood Collection. A unitof FFP contains about 200 units of Factor VIII as well as othercoagulation factors. Volume is 250 cc.b. Compatibility: ABO compatibility requiredc. Alternatives:i. Specific coagulation factors (cryoprecipitate for low fibrinogen or vonWillebrand's disease)ii. Crystalloid or albumin is the preferred product for volume expansion d.

Indications:1. Replacement of isolated deficiencies (Factor II, V, VII, IX, XI) ii. Reversal ofWarfarin effectiii. Massive blood transfusion (greater than 1 blood volume within severalhours)iv. Antithrombin III Deficiencyv. Thrombotic thrombocytopenia purpurae. Adverse reactions: Same as with RBC's


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5.

Albumina. Description: A solution containing the albumin component of humanblood, which can effect immediate and prolonged restoration of circulatingblood volume by causing a shift of fluid from the interstitial spaces into thecirculation and slightly increasing the concentration. of plasma proteinsb. Action: 25% albumin will draw approximately 3.5 times its volume ofadditional fluid into the circulation within 15 minutes, and provides a meansof replacing human plasma proteinsc. Indications:i. Plasma or blood volume deficit secondary to surgery, hemorrhage, burns, ortrauma: to support BP by expanding the plasma volumeii. Hemolytic disease in the newborniii. Hypovolemic shock: to restore blood volume in increase COiv. Hemodialysis: for the treatment of shock or hypotension when thepatient is fluid overloadedv. Acute or chronic liver diseased. Contraindications: History of hypersensitivity or severe anemia or CHFe. Precautions: Solutions containing 5% albumin are usually indicated forhypovolemic patients, 25% solutions should be used when fluid and Na+intake must be minimized (cerebral edema and pediatric patients)f. Adverse reactions: Rare

NOTE* Allergic reaction, dermal and anaphylaxis can be severe.Treatment includes Benadryl 50 mg 1M STAT repeated Q 10-20minutes prn. Steroids and fluids may be necessary in severereactions

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Hersheychapter 1