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Severe hypothermia
Severe Hypothermia
• Temperature is < 30Centigrade (86 F)
• Marked depression of critical body functions
• Intact neurologic recovery maybe possible
after hypothermic cardiac arrest
General Care of hypothermic patients
with perfusion
• Mild > 34 *C : Passive rewarming
• Moderate 30-34 *C : Active external
rewarming
• Severe < 30*C : Active internal rewarming
Modifications in the BLS in
hypothermic arrested patients
• ABC life support
• Prolong assessment of Breathing and pulses
30 -45 seconds to confirm respiratory arrest ,
pulseless or bradycardia
• Give warmed humidified oxygen via BVM
• When in doubt start CPR
Modifications in ACLS
• Endotracheal intubation is appropriate
• More aggressive active core rewarming technique
• Give medicatons once core temperature > 30 C with
increased intervals between doses.
• May attempt defibrillation once for VF and Pulseless VT in
severe hypothermia
• Succeeding defibrillation attempt once temperature 30-32 C.
• Intubate patients give warm humidified O2 at 42-46C
• rewarm patients using warmed IVF at 43C
Near Fatal Asthma
• 2M visits per year in the ER
• 5000-6000 deaths per year
• 2-20% admitted in ICU
• Pathophysiology:
– Bronchoconstriction
– Airway inflammation
– Mucus impaction
Near Fatal Asthma
• Primary therapy
– Oxygen
– Inhaled Beta 2 agonist
– Corticosteroids
Near Fatal Asthma
• Adjunctive Therapies
– Anticholinergic agents
– Magnesium Sulfate
– Parenteral epinephrine or terbutaline
– Ketamine
– Heliox
– Methylxanthines
– Leukotriene Antagonist
Near Fatal Asthma
• Non-invasive Positive Pressure Ventilation
• ETT with mechanincal ventilation
• Common causes of deterioration among
intubated patients:
– Tube dispalcement
– Obstruction
– Pneumothorax
– Equipment failure
Drowning
Drowning
• Primary respiratory impairment from
submersion/immersion in a liquid medium
• Hypoxia is the most important consequence
• Immediate oxygenation, ventilation and
perfusion should be restored
• Bystander CPR and Activation of EMS
• All victims should be brought to hospital
Drowning
Modifications in BLS in Drowning
• Immediate rescue of victim
• Personal safety
• Routine Cervical stabilization is not necessary
• Management is patients airway and breathing is the
most important
• No need to clear the airway of aspirated water
• Pulse check is difficult in cold water
• Chest compression in water by trained professionals
Modifications in BLS for Drowning
• Vomiting during CPR is common
• May log roll patient for suspected neck injury
• Suction , turn victims head to the side or use
finger sweeping .
ACLS in Drowning
• Intubation
• Defibrillation
• Therapeutic hypothermia
Anaphylaxis
Anaphylaxis
• Severe, systemic allergic reaction
characterized by multisystem involvement
• Hypersensitivity reactions mediated by IgE
and IgG
• Re-exposure to the allergen provokes the
anaphylactic reaction
• Histamines , leukotrienes, prostaglandins,
thromboxanes, bradykinins
Anaphylaxis
• Causes: pharmacologic agents, latex, stinging
insects, foods
• Signs and symptoms: laryngeal edema, rhinitis,
wheezing, agitated, pale, flushed, diarrhea,
abdominal pain, vomiting
• Cardiovascular collapse most common
periarrest manifestation
Differential diagnosis
• Scombroid poisoning – urticaria, nausea,
vomiting and headache
• Hereditary Angioedema- urticaria does not
occur.
• ACE inhibitors- develop angioedema of the
airways
• Severe, near fatal asthma
• Panic disorders- stridor but no urticaria,
angioedema or hypoxia
Interventions to anaphylaxis
• High flow oxygen
• Elective intubation if presence of lingual edema,
sudden hoarseness, stridor
• Epinenphrine
• Fluid resuscitation PNSS
• Antihistamines
• H2 blockers
• Inhaled Beta adrenergic agents
• Corticosteroids
• Removal of offending agents
Epinephrine pen
Airway obstruction secondary to
anaphylaxis
Airway obstruction
• Hoarseness, lingual edema, oropharyngeal
swelling ->>>>risk for respiratory compromise
early elective intubation
• WOF: progressive stridor, dysphonia,
laryngeal edema, massive lingual swelling,
facial and neck swelling -> advance airway
technique
Cardiac arrest
• Massive volume expansion
• High dose epinephrine IV
• Antihistamine IV
• Steroid therapy
• Prolonged CPR
Cardiac Arrest associated with trauma
• Prehospital resuscitation is focused in safe
extrication, stabilize patient and minimize
intervention that will delay transport to
definitive care.
• Attempts to stabilize patients are performed
during transport to avoid delay
Safe extrication Immediate transport
BLS in trauma arrested patients
• Airway : jaw-thrust maneuver with C-spine control
• Breathing : ventilation provided by barrier devices
such as pocket mask or BVM.
• Circulation : 30 compressions : 2 ventilations and
Direct compression applied to visible hemorrhage
• Disability : assess victims response and signs of
deterioration
• Exposure : remove clothing to define extent of
injury
ACLS in trauma arrested patients
• Airway
– Endotracheal intubation done while maintaining
spine immobilization
– Confirmation of tube placement via exhaled CO2
monitor or Esophageal Detector Device
– Cricothyrotomy for failed endotracheal intubation
Trauma arrest
• Breathing
– High concentrated O2 needed
– Assess breath sounds and chest expansion
– Tension pneuthorax and hemothorax common
• Circulatory
– Large bore IV access
– Crystalloids and pack RBC
– Urban setting : aggressive prehospital volume
resuscitation no longer recommended - increase blood
pressure accelerate rate of blood loss delay in
surgical intervention
Trauma arrest
• Circulatory
– Most common cardiac rhythm is PEA or pulseless
Electrical Activity and Bradyasystolic rhythm treat
with CPR and look for underlying causes
– If Ventricular Fibrillation or Ventricular
tachycardia treat with CPR and Defibrillation
– Emergency Thoracotomy lifesaving for
penetrating chest trauma who arrested few
minutes before ER or while in the ER consult.
Cardiac arrest associated with
Pregnancy
• Two potential patients
• Best hope for fetal survival is maternal
survival
• Consider physiologic changes in pregnancy
Modifications in BLS
• Airway / Breathing : insufficiency in the
gastroesophageal sphincters cricoid
pressure during positive pressure ventilation
• Circulation : 15-30 degrees back left lateral
decubitus, higher on the sternum during
compression
• Defibrillation : no adverse affect on the heart
of the fetus
Modifications in ACLS
• Early insertion of advance airway due to increase risk
of regurgitation
• Use smaller tube due to airway edema and swelling
• Effective preoxygenation
• Gravid uterus elevates diaphragm less O2 reserve
due decrease functional residual capacity
hypoxemia
• Ventilation volume should be reduced due elevated
mothers diaphragm
Modifications in ACLS
• Vasopressor agents will decrease blood flow
to the uterus
• Maternal resuscitation determines fetal
survival
• Familiarization of pregnancy specific disease
and procedural complications
• Excess Magnesium sulfate
• Acute coronary syndrome
• Pre-eclampsia or Eclampsia
• Aortic dissection
• Life threatening pulmonary embolism and
stroke
• Amniotic fluid embolism
• Trauma and drug overdose
Emergency Hysterotomy
• Emergency cessarian delivery in pregnant
women
• More than 24-25 weeks gestation
• Four minutes after cardiac arrest
• Delivery of the baby empties uterus free
inferior vena cava and aorta restore venous
return and cardiac output
Decision making
• Consider gestational age: fetal viability is >24-
25 weeks AOG
• Less than 20 weeks : don’t deliver
• 20 -23 weeks AOG : deliver fetus to enable
successful maternal resuscitation
• > 24-25 weeks AOG : resuscitation for both
mother and baby
Decision Making
• Features of cardiac arrest (increase chance of
infant survival)
– Short interval of maternal arrest and infant
delivery
– No persistent hypoxia to the mother
– No fetal distress
– Aggressive and effective resuscitation to the
mother
– Hysterotomy performed in hosp with NICU