Special Resuscitation Situations

Presented by :Abdulgadir F. Bugdadi

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

SPECIAL RESUSCITATION SITUATIONS

• Near Drowning.• Hypothermia.• Trauma.• Electrical shock.

Objectives

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

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.

Effects

1.CNS effects.

2.pulmonary effects.

3.CVS effects.

NEAR DROWNING

• Spinal cord injury (diving)• Air embolism or “the bends” (SCUBA)• Hypothermia

Possible Associated Injuries

NEAR DROWNING

• Alcohol or other drug ingestion.• Hypoglycemia.• Seizures.• Cardiac disease, dysrhythmias, and

syncope.• Suicide, homicide, or child abuse.

Possible underlying causes

NEAR DROWNING

• Rescuer safety.• Reach and remove the victim from water.• Protect cervical spine if trauma is suspected.• Start CPR.

Pre-hospital Resuscitation

NEAR DROWNING

• Remove particulate matter via finger sweep.• Heimlich maneuver ONLY for particulate matter or

foreign body.

Pre-hospital Resuscitation (cont.)

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

Emergency Department Management (Cont.)

• Continue CPR (if needed)

• Intubation and mechanical ventilation (if indicated).

• Rapid volume expansion.• Cardiac monitor.

• Rewarm if hypothermic.

NEAR DROWNING

• Check CBC, BUN, electrolytes.• Arterial blood Gases.• Foley catheter.• N/G tube if unresponsive.

Additional Procedures

NEAR DROWNING

• Survival possible with prolonged submersion in cold water – especially in children

• Best predictor – early awakening following resuscitation

Prognosis

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.

TRAUMATIC CARDIAC ARREST

As in any arrested patient begin management with

ABC

Initial Management

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

TRAUMATIC CARDIAC ARREST

• Immediate thoracotomy.• Open chest CPR.

Penetrating Chest Injury

ELECTRICUTION

• >90% caused by generated electricity.• Low-voltage deaths – home or workplace.• High-voltage deaths – 86% at workplace.

Epidemiology

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

ELECTRICUTIONEffect of Current Intensity

< 1mA : Tingling

5-30mA: “Let go current”

40-50mA: Respiratory arrest

> 100mA: Ventricular fibrillation

> 10A: Prolonged apnea

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)

ELECTRICUTION

• Cervical spine or other bony fracture.

• Head injury.• Myoglobinuria.

Remember Secondary Injury

ELECTRICUTION

• Massive DC counter shock.• Death in 30% of victims.• Nearly all deaths follow immediate arrest.

Lightning Injury

ELECTRICUTION

• Turn off current.

• ABC’s of CPR.

• Protect cervical spine and treat injuries.

Management

• 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.

• Surgical consultation.

HYPOTHERMIA

• Definition: core body temperature <35oC.

• Incidence: children/elderly most susceptible.

Definition/incidence

Classification

• Mild ; 32 – 35 °C.• Moderate ; 30 – 32 °C.

• Severe ; < 30 °C.

• Warning :May be missed if thermometer does not read below 34.4oC.

HYPOTHERMIA

• Immersion in cold water.• Cold weather exposure.• Impaired thermoregulation – elderly,

infants, drug or alcohol ingestion, diabetes, infection.

Common Clinical Situations

HYPOTHERMIA

• Inhibits release of ADH – diuresis/dehydration.• Hematocrit and viscosity of blood increase.• Insulin release and peripheral utilization inhibited –

elevated blood sugar.

Physiological Consequences

HYPOTHERMIA

• Shivering.• Tachycardia, hypertension,

hyperventilation.• Memory loss.• Poor judgment.

Clinical Features – Mild hypothermia.

HYPOTHERMIA

• Bradycardia.• Arrhythmias.• Hypotension.• Altered level of

consciousness.• Rigidity.• Eventual VF or

asystole.

Clinical Features – Moderate to Severe hypothermia.

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

HYPOTHERMIA

• Intubate if indicated.• Antiarrhythmics usually unnecessary.• Treat hypoglycemia with D50W.• Treat volume depletion with N/S or L/R.

Treatment Principles (cont.)

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

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)

HYPOTHERMIA

Warning ;• Rapid external rewarming can cause vasodilation.

Rewarming Shock

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)

• For dysrhythmia , Bretylum tosylate (only known to be effective).

HYPOTHERMIA

• Must be individualized by the physician in charge of the resuscitation based on unique circumstances of each incident

Decision to Terminate Resuscitation

END

Thank You

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

PREGNANCY

• Arrhythmia• Congestive heart failure• Pulmonary embolism• Intracranial or hepatic hemorrhage

Precipitants of Cardiac Arrest

PREGNANCY

• Supine position compresses aorta and inferior vena cava

• Rolling mother to left side may increase cardiac output by 25%

Supine Hypotension

PREGNANCY

• Before onset of fetal viability – save mother’s life• Conventional CPR/ACLS as indicated

Management of Cardiac Arrest (<24 weeks’ gestation)

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