Special Resuscitation Situations

1. Special Resuscitation Situations Presented by : Abdulgadir F. Bugdadi

2. SPECIAL RESUSCITATION SITUATIONS Objectives • To understand the unique considerations involved in the common special resuscitation situations. 2. To be able to modify resuscitation efforts for special situations.

3. SPECIAL RESUSCITATION SITUATIONS Objectives • Near Drowning. • Hypothermia. • Trauma. • Electrical shock.

4. NEAR DROWNING Definitions • 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.

5. NEAR DROWNING Epidemiology in U.S.A. • 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.

6. Effects 1.CNS effects. 2.pulmonary effects. 3.CVS effects.

7. NEAR DROWNING Possible Associated Injuries • Spinal cord injury (diving) • Air embolism or “the bends” (SCUBA) • Hypothermia

8. NEAR DROWNING Possible underlying causes • Alcohol or other drug ingestion. • Hypoglycemia. • Seizures. • Cardiac disease, dysrhythmias, and syncope. • Suicide, homicide, or child abuse.

9. NEAR DROWNING Pre-hospital Resuscitation • Rescuer safety. • Reach and remove the victim from water. • Protect cervical spine if trauma is suspected. • Start CPR.

10. NEAR DROWNING Pre-hospital Resuscitation (cont.) • Remove particulate matter via finger sweep. • Heimlich maneuver ONLY for particulate matter or foreign body.

11. NEAR DROWNING Emergency Department Management • Note ; • Most important critical goal is correction of hypoxia and acidosis. • Most acidosis is restored after correction of volume depletion and oxygenation. • Hypothermia may also be present and exacerbate bradycardia, acidosis, and hypoxemia.

12. Emergency Department Management (Cont.) • Continue CPR (if needed) • Intubation and mechanical ventilation (if indicated). • Rapid volume expansion. • Cardiac monitor. • Rewarm if hypothermic.

13. NEAR DROWNING Additional Procedures • Check CBC, BUN, electrolytes. • Arterial blood Gases. • Foley catheter. • N/G tube if unresponsive.

14. NEAR DROWNING Prognosis • Survival possible with prolonged submersion in cold water – especially in children • Best predictor – early awakening following resuscitation

15. TRAUMATIC CARDIAC ARREST • Important concepts for traumatic patients : • In any patient with trauma suspect cervical injury specially with the mechanism of injury. • In arrested patient with chest trauma, suspect cardiac tamponade and tension pneumothorax.

16. TRAUMATIC CARDIAC ARREST Initial Management As in any arrested patient begin management with ABC

17. TRAUMATIC CARDIAC ARREST Remember in a trauma patient • Volume resuscitation – 2 liters of fluids through 2 large bore I.V. canula. • Signs of tension pneumothorax. • Signs of cardiac tamponade.

18. TRAUMATIC CARDIAC ARREST Penetrating Chest Injury • Immediate thoracotomy. • Open chest CPR.

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

20. ELECTRICUTION Danger of Cardiac Arrest • 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).

21. ELECTRICUTION Effect of Current Intensity

22. ELECTROCUTION Thermal Injury (Electrical burns) • Electricity travels along nerves and blood vessels • Burns are often full thickness; may extend to bone; may require debridement, escharotomy, fasciotomy, or amputation.

23. ELECTRICUTION Remember Secondary Injury • Cervical spine or other bony fracture. • Head injury. • Myoglobinuria.

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

25. ELECTRICUTION Management • Turn off current. • ABC’s of CPR. • Protect cervical spine and treat injuries.

26. 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.

27. Surgical consultation.

28. HYPOTHERMIA Definition/incidence • Definition: core body temperature <35oC. • Incidence: children/elderly most susceptible.

29. Classification • Mild ; 32 – 35 °C. • Moderate ; 30 – 32 °C. • Severe ; < 30 °C.

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

31. HYPOTHERMIA Common Clinical Situations • Immersion in cold water. • Cold weather exposure. • Impaired thermoregulation – elderly, infants, drug or alcohol ingestion, diabetes, infection.

32. HYPOTHERMIA Physiological Consequences • Inhibits release of ADH – diuresis/dehydration. • Hematocrit and viscosity of blood increase. • Insulin release and peripheral utilization inhibited – elevated blood sugar.

33. HYPOTHERMIA Clinical Features – Mild hypothermia. • Shivering. • Tachycardia, hypertension, hyperventilation. • Memory loss. • Poor judgment.

34. HYPOTHERMIA Clinical Features – Moderate to Severe hypothermia. • Bradycardia. • Arrhythmias. • Hypotension. • Altered level of consciousness. • Rigidity. • Eventual VF or asystole.

35. HYPOTHERMIA Treatment Principles • 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.

36. HYPOTHERMIA Treatment Principles (cont.) • Intubate if indicated. • Antiarrhythmics usually unnecessary. • Treat hypoglycemia with D50W. • Treat volume depletion with N/S or L/R.

37. HYPOTHERMIA Pre-hospital Management • Minimize further heat loss ; • Remove wet garments. • Use blankets/sleeping bag. • Warm rescuer can lie next to victim. • Warm humidified oxygen. • Transport cautiously and gently.

38. HYPOTHERMIA Management – Mild to Moderate (> 30oC) • Passive or active external rewarming ; • Warm room. • Warm blanket. • Warm clothing. • Warm I.V. fluids (43oC). • Raise temperature 0.5-1.0oC per hour. • Prognosis good.

39. HYPOTHERMIA Rewarming Shock Warning ; • Rapid external rewarming can cause vasodilation.

40. HYPOTHERMIA Management – Severe (< 30oC) 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.

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

42. HYPOTHERMIA Decision to Terminate Resuscitation • Must be individualized by the physician in charge of the resuscitation based on unique circumstances of each incident

43. END Thank You

44. PREGNANCY Cardiovascular Changes in Mother • 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

45. PREGNANCY Precipitants of Cardiac Arrest • Arrhythmia • Congestive heart failure • Pulmonary embolism • Intracranial or hepatic hemorrhage

46. PREGNANCY Supine Hypotension • Supine position compresses aorta and inferior vena cava • Rolling mother to left side may increase cardiac output by 25%

47. PREGNANCY Management of Cardiac Arrest (<24 weeks’ gestation) • Before onset of fetal viability – save mother’s life • Conventional CPR/ACLS as indicated

48. PREGNANCY Management of Cardiac Arrest (>24 weeks’ gestation • 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