Special Resuscitation Situations

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Special Resuscitation Situations

• Presented by
• Abdulgadir F. Bugdadi

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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.

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SPECIAL RESUSCITATION SITUATIONS
Objectives

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

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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.

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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.

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Effects

• 1.CNS effects.
• 2.pulmonary effects.
• 3.CVS effects.

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NEAR DROWNING
Possible Associated Injuries

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

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NEAR DROWNING
Possible underlying causes

• Alcohol or other drug ingestion.
• Hypoglycemia.
• Seizures.
• Cardiac disease, dysrhythmias, and syncope.
• Suicide, homicide, or child abuse.

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NEAR DROWNING
Pre-hospital Resuscitation

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

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NEAR DROWNING
Pre-hospital Resuscitation (cont.)

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

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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.

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

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NEAR DROWNING
Additional Procedures

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

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NEAR DROWNING
Prognosis

• Survival possible with prolonged submersion in
  cold water especially in children
• Best predictor early awakening following
  resuscitation

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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.

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TRAUMATIC CARDIAC ARREST
Initial Management

• As in any arrested patient begin management
  with
• ABC

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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.

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TRAUMATIC CARDIAC ARREST
Penetrating Chest Injury

• Immediate thoracotomy.
• Open chest CPR.

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ELECTRICUTION
Epidemiology

• gt90 caused by generated electricity.
• Low-voltage deaths home or workplace.
• High-voltage deaths 86 at workplace.

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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).

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ELECTRICUTION
Effect of Current Intensity
lt 1mA Tingling
5-30mA Let go current
40-50mA Respiratory arrest
gt 100mA Ventricular fibrillation
gt 10A Prolonged apnea
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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.

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ELECTRICUTION
Remember Secondary Injury

• Cervical spine or other bony fracture.
• Head injury.
• Myoglobinuria.

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ELECTRICUTION
Lightning Injury

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

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ELECTRICUTION
Management

• Turn off current.
• ABCs of CPR.
• Protect cervical spine and treat injuries.

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• 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.

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• Surgical consultation.

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HYPOTHERMIA
Definition/incidence

• Definition core body temperature lt35oC.
• Incidence children/elderly most susceptible.

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• Classification
• Mild 32 35 C.
• Moderate 30 32 C.
• Severe lt 30 C.

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

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HYPOTHERMIA
Common Clinical Situations

• Immersion in cold water.
• Cold weather exposure.
• Impaired thermoregulation elderly, infants,
  drug or alcohol ingestion, diabetes, infection.

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HYPOTHERMIA
Physiological Consequences

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

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HYPOTHERMIA
Clinical Features Mild hypothermia.

• Shivering.
• Tachycardia, hypertension, hyperventilation.
• Memory loss.
• Poor judgment.

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HYPOTHERMIA
Clinical Features Moderate to Severe
hypothermia.

• Bradycardia.
• Arrhythmias.
• Hypotension.
• Altered level of consciousness.
• Rigidity.
• Eventual VF or asystole.

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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 gt 30 C.

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HYPOTHERMIA
Treatment Principles (cont.)

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

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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.

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HYPOTHERMIA
Management Mild to Moderate (gt 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.

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HYPOTHERMIA
Rewarming Shock

• Warning
• Rapid external rewarming can cause vasodilation.

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HYPOTHERMIA
Management Severe (lt 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.

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

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HYPOTHERMIA
Decision to Terminate Resuscitation

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

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END

• Thank You

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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

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PREGNANCY
Precipitants of Cardiac Arrest

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

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PREGNANCY
Supine Hypotension

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

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PREGNANCY
Management of Cardiac Arrest (lt24 weeks
gestation)

• Before onset of fetal viability save mothers
  life
• Conventional CPR/ACLS as indicated

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PREGNANCY
Management of Cardiac Arrest (gt24 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