Special Resuscitation Situations Presented by : Abdulgadir F. Bugdadi
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.
SPECIAL RESUSCITATION SITUATIONS Objectives • Near Drowning. • Hypothermia. • Trauma. • Electrical shock.
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.
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.
Effects 1.CNS effects. 2.pulmonary effects. 3.CVS effects.
NEAR DROWNING Possible Associated Injuries • Spinal cord injury (diving) • Air embolism or “the bends” (SCUBA) • Hypothermia
NEAR DROWNING Possible underlying causes • Alcohol or other drug ingestion. • Hypoglycemia. • Seizures. • Cardiac disease, dysrhythmias, and syncope. • Suicide, homicide, or child abuse.
NEAR DROWNING Pre-hospital Resuscitation • Rescuer safety. • Reach and remove the victim from water. • Protect cervical spine if trauma is suspected. • Start CPR.
NEAR DROWNING Pre-hospital Resuscitation (cont.) • Remove particulate matter via finger sweep. • Heimlich maneuver ONLY for particulate matter or foreign body.
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.
Emergency Department Management (Cont.) • Continue CPR (if needed) • Intubation and mechanical ventilation (if indicated). • Rapid volume expansion. • Cardiac monitor. • Rewarm if hypothermic.
NEAR DROWNING Additional Procedures • Check CBC, BUN, electrolytes. • Arterial blood Gases. • Foley catheter. • N/G tube if unresponsive.
NEAR DROWNING Prognosis • Survival possible with prolonged submersion in cold water – especially in children • Best predictor – early awakening following resuscitation
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.
TRAUMATIC CARDIAC ARREST Initial Management As in any arrested patient begin management with ABC
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.
TRAUMATIC CARDIAC ARREST Penetrating Chest Injury • Immediate thoracotomy. • Open chest CPR.
ELECTRICUTION Epidemiology • >90% caused by generated electricity. • Low-voltage deaths – home or workplace. • High-voltage deaths – 86% at workplace.
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).
ELECTRICUTION Effect of Current Intensity
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.
ELECTRICUTION Remember Secondary Injury • Cervical spine or other bony fracture. • Head injury. • Myoglobinuria.
ELECTRICUTION Lightning Injury • Massive DC counter shock. • Death in 30% of victims. • Nearly all deaths follow immediate arrest.
ELECTRICUTION Management • Turn off current. • ABC’s of CPR. • Protect cervical spine and treat injuries.
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.
HYPOTHERMIA Definition/incidence • Definition: core body temperature <35oC. • Incidence: children/elderly most susceptible.
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 Common Clinical Situations • Immersion in cold water. • Cold weather exposure. • Impaired thermoregulation – elderly, infants, drug or alcohol ingestion, diabetes, infection.
HYPOTHERMIA Physiological Consequences • Inhibits release of ADH – diuresis/dehydration. • Hematocrit and viscosity of blood increase. • Insulin release and peripheral utilization inhibited – elevated blood sugar.
HYPOTHERMIA Clinical Features – Mild hypothermia. • Shivering. • Tachycardia, hypertension, hyperventilation. • Memory loss. • Poor judgment.
HYPOTHERMIA Clinical Features – Moderate to Severe hypothermia. • Bradycardia. • Arrhythmias. • Hypotension. • Altered level of consciousness. • Rigidity. • Eventual VF or asystole.
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.
HYPOTHERMIA Treatment Principles (cont.) • Intubate if indicated. • Antiarrhythmics usually unnecessary. • Treat hypoglycemia with D50W. • Treat volume depletion with N/S or L/R.
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.
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.
HYPOTHERMIA Rewarming Shock Warning ; • Rapid external rewarming can cause vasodilation.
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.
For dysrhythmia , Bretylum tosylate (only known to be effective).
HYPOTHERMIA Decision to Terminate Resuscitation • Must be individualized by the physician in charge of the resuscitation based on unique circumstances of each incident
END Thank You
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
PREGNANCY Precipitants of Cardiac Arrest • Arrhythmia • Congestive heart failure • Pulmonary embolism • Intracranial or hepatic hemorrhage
PREGNANCY Supine Hypotension • Supine position compresses aorta and inferior vena cava • Rolling mother to left side may increase cardiac output by 25%
PREGNANCY Management of Cardiac Arrest (<24 weeks’ gestation) • Before onset of fetal viability – save mother’s life • Conventional CPR/ACLS as indicated
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