Lab6: Special Situations In Cpr

SPECIAL SITUATIONS IN CPR

Special circumstances • Common cause of • cardio-respiratory arrest in young • Cardiac arrest could be often prevent • Some patients require prolonged resuscitation

Hypothermia Definition: Core temperature <35 ° C (thermometer reading low temperature) Light 32 to 35 ° C Average 30 to 32 ° C Severe <30 ° C

Hypothermia Special problems: immersion extreme ages injury / illness Drugs / alcohol

Clinical features of hypothermia • • • • •

Pulse: slow, irregular, filiform TA: low or unmeasured Pupil: dilated CNS: altered mental status, coma Hypothermia is primary or secondary ?

Atention ! • Clinical features of hypothermia may mimic death • Effect of brain protection • "The patient is not dead until it is warm and dead", except that: • fatal injuries are obvious • body is so frozen that resuscitation is impossible

Airways and breathing • Oxygen in high concentration, humidifier and heated (40-46 ° C) • Tracheal intubation under ACLS algorithm • Ventilation observe chest rise

Breath • Oxygen in high concentration • Intubation unconscious patients • Arterial blood gas analysis (Astrup arteriosus) • IOT - rapid induction cricoidian pressure (requiring specialists)

Circulation • • • • •

Notice the extreme bradycardia Consider the Doppler examination Oesophageal temperature Thoracic stiffness is increased Central veins or proximal to large size

Arrhythmias associated with hypothermia Sinus bradycardia Atrial fibrillation Fibrillation Asistolie

Temperature

Circulation • Defibrillator may fail if core temperature is> 30 ° C • Other types of arrhythmias are spontaneous improved, while increasing temperature • The efficacy of drugs is reduced to a temperature <30 ° C • Bradycardia may be physiological in severe hypothermia

Patient Warming • Remove patient from cold environment • Mobilization may precipitate the emergence of arrhythmias • Prevent further heat loss • Quickly transported patient to hospital • Remove clothes cold / wet

Active heating External Blankets with hot air Heated Chamber Internal Extracorporeal circulation Ventilation with 02 heated and Humidifier Hot fluid i.v. (40 º C) Gastric lavage, peritoneal, pleural and bladder with warm liquid Continuous veno-venous haemofiltration

Monitoring and investigations • • • • • •

Continuous hemodynamic monitoring Repeated blood gas analysis do not use temperature correction ! Electrolytes hyperkalaemia during heating Thyroid function (elderly)

Immersion and submersion • Immersion - head above water • hypothermia • cardiovascular instability • Submersion - head in the water – asphyxia – hypoxia - secondary cardiac • Drowning-death within 24 hours of submersion

Resuscitation decision • Complete return is possible even after a prolonged immersion • Increased risk of hypothermia if the water temperature <25 ° C • Submersion due to seizures or alcohol?

Saving from water • Minimize risk of rescuers • Suspected of spine injury • Keeping the patient in horizontal position • Do not start resuscitation in the water unless you are trained for this

Airways and breathing • • • • •

Caution: possible spine injury Administer 100% oxygen Do not try to "Drain the lungs" Vomiting is common Early intubation if the patient is unconscious

Airways and breathing • Ventilation should be initiated as soon as possible, safely for rescuer (in shallow water or ashore) • It opens air ventilation and administered for 1 minutes • If the victim can be brought to shore in less than 5 min. continue vents • If the distance is bigger vent 1 minutes and try to bring faster the victim to shore without the other breaks for ventilation

Circulation • Notice the extreme bradycardia • "Hypovolemia" caused by the removal of hydrostatic pressure exerted by water on the body during immersion • Intravenous fluids • Nasogastric tube • No matter if the phenomenon occurred in fresh / salt

Investigations – Astrup artery – Electrolytes – Blood sugar – ECG – Rx. lung

Poisoning • One of the main causes of death in people under 40 years • The most common are voluntary poisoning with drugs or drug agents • Industrial accident or exposure during war: • chemical contamination • radiation

Resuscitation: airways • Altered state of consciousness is usually in the case: – airway obstruction • respiratory arrest • Avoid mouth-to-mouth for poisoning with: – cyanide – Hydrogen sulphide – corrosive substances – organophosphorus

Circulation • Hypotension induced by drugs is common • Fluid therapy + / - inotropic medication • Acid-base imbalances • Synchronous cardioversion for lifethreatening arrhythmias

Specific antidotes • Paracetamol - N-acetilcisteină • Organophosphorus - Atropine • Cyanide - Sodium nitrite - sodium thiosulphate - Cobalt EDTA • Digoxin - Fab Antibodies • Opioids - naloxone

Specific therapeutic measures • Limiting absorption of toxic substances ingested • gastric lavage <1hr • activated charcoal • bowel irrigation • Growth removal – hemodialysis – hemoperfusion • Specific antidotes

Management • • • •

Prolonged coma-rhabdomyolysis Electrolytes (K +) and blood sugar Blood gases (arterial Astrup) Temperature

Pregnancy: causes of cardiac arrest in pregnant • Bleeding • Pulmonary embolism • Embolism with amniotic fluid • Detachment of the placenta • Eclampsia • Drug intoxication

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Resuscitation in pregnancy • It takes two people • Early involvement of an obstetrician and a neonatology

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Airways • Increased risk of regurgitation • Cricoidian pressure • Tracheal intubation (difficult): • thickening of neck • chest size • glottis edema RC (UK)

Breath Difficult because: Diaphragm is ascensioned and limit his movements It may be necessary a high pressure insufflation

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Circulation • The uterus flatening the inferior vena cava • Moving the uterus : – Semidecubit left side – Manual handling • Restoration volemiei • Immediate surgery if bleeding

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Emergency caesarean In the 3rd trimester of pregnancy, if resuscitation is unsuccessful in the first 5 minutes

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• At a gestational age of 20-23 weeks, caesarean section will be done in order to maternal resuscitation • At a gestational age> of 24-25 weeks, caesarean section in order to perform resuscitation of both mother and fetus RC (UK)

Electrocution

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Electrocution • • • •

Electricity (AC): housewife Industrial Flash (DC)

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Factors influencing the severity

• Current type and route it through the body • alternating (AC) - more frequent FV • continuous (DC) - more frequent asystola • Voltage current • Current intensity delivered • Resistance to electricity • Area and duration of contact

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Lightning • Cardiac depolarisation • asystola or FV(ventricular fibrilation) • Paralysis of respiratory muscles may cause respiratory arrest • Extended Neurological Injury RC (UK)

Rescuer safety • Pause power source • High voltage current can: – produce arc – to spread through the ground

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CPR • BLS and early ALS • Early intubation if the / neck burns presents • Muscle paralysis may persist for 30 min after high-voltage shocks RC (UK)

Anaphylaxis • Anaphylaxis - hypersensitivity reaction mediated by IgE • Non-allergic anaphylaxis - does not involve hypersensitivity • Similar events and treatment

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Clinical signs • • • •

Angioedema - swelling laringean Rush (urticaria / erythema) Hypotension vasodilatation and increased vascular permeability • Bronchoconstriction • Rhinitis, conjunctivitis • Abdominal pain, vomiting and diarrhea RC (UK)

• • • • • • • •

CPR

Removing allergen agent High-flow oxygen Adrenaline Anaphylactic reaction - 0.5 mg 1:1000 i.m. or s.c. Severe anaphylactic shock - 0,1-0,5 mg iv 1:10.000 Fluids Antihistamines - H1 blockers, consider administration of H2 blockers Hydrocortisone and inhaled beta 2 mimetic RC (UK)

Attention to early relapses ! • • • •

Serious reactions triggered slow Reactions in patients with asthma Continue allergen absorption agent History of biphasic reactions

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Severe Acute Asthma • Reversible • Death is avoidable • patients require medical attention too late • delayed medical personnel • premature discharge RC (UK)

Asthma and cardiac arrest • Causes: • - Severe bronchospasm and mucus hypersecretion • - Cardiac arrhythmias caused by hypoxia or the administration exaggerated by beta-agonists • - Auto PEEP (positive pressure at the end expired) in some patients intubated and mechanically ventilated - not expire all inspired air - increase in airway pressure - reduced venous return - reduces cardiac output • - Suffocating pneumothorax usually bilateral RC (UK)

Characteristics of potentially fatal asthma • • • • • • •

Silentium chest Cyanosis Bradycardia Hypotension Asthenia Coma Hypoxia, acidemie, + /-hipercarbie RC (UK)

Treatment • • • • •

Concentrated oxygen Nebulisation with beta 2 mimetic Steroids Subcutaneous epinephrine 300 microgr Inhaled anticholinergics, aminophylline i.v. • Liquids RC (UK)

Treatment • Mechanical ventilation only when drug therapy was not effective • You may not obtain normalization of blood gas

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CPR • Pulmonary ventilation difficult • mask ventilation increased gastric dilation • Early intubation • Pneumothorax risk • Effective chest compressions is difficult • It will consider open heart massage RC (UK)

Cardiac arrest associated with trauma Causes: Serious brain damage Hypovolemia, hypoxia Damage vital organs Suffocating pneumothorax Cardiac tamponade Major medical problems RC (UK)

CPR in trauma • Identification and treatment of serious injuries before installing cardiac arrest • Protect cervical spine • Hypoxia and / or hypovolemia → PEA • Oxygen, stop bleeding, fluid • Thoracothomia - resuscitation for cardiac arrest associated with penetrating wounds RC (UK)

Internal cardiac massage Indications • • • •

Recent heart surgery PEA after trauma Hiperinflaţi lungs or chest rigid During abdominal or thoracic surgery RC (UK)

Summary • Fair treatment, performed in time can prevent cardiac arrest • Change advanced resuscitation techniques to treat cardiac arrest occurred in special circumstances

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