Special Resuscitation Situations

Roderick T. Vito, M.D.

Department of Emergency Medicine
 Stroke
• Each year 700,000 suffer stroke
• 155,000 among them die
• Fibrinolytic therapy can limit neurologic
damage from stroke and improve outcome
• Time available for treatment is limited
 Stroke
• Sudden onset illness caused by an occlusion
( ischemic) or rupture (hemorrhagic) of a
blood vessel in the brain
• Majority of stroke is due to occlusion of the
blood vessel
 Stroke Chain of Survival
1. Rapid recognition of and reaction to stroke
warning signs
2. Rapid emergency medical services dispatch
3. Rapid EMS system transport and prehospital
notification
4. Rapid diagnosis and treatment in the
hospital
 Stroke Warning signs
• Sudden weakness or numbness of the
face,arm or leg on one side of the body
• Sudden confusion, trouble speaking or
understanding
• Sudden trouble seeing, walking
• Dizziness, loss of balance or coordination
• Sudden severe headache with no known
cause
 EMS stroke dispatch
• <10% with acute ischemic stroke are
ultimately eligible for fibrinolytic therapy
• Education and training of EMS personnel is
important for the timely response to stroke
victims
 Stroke Assessment Tools
• Cincinnati Prehospital • Los Angeles
Stroke Scale Prehospital Stroke
– Facial Droop Screen
– Arm Drift – Age >45
– Abnormal Speech – Hx of Seizure or epilepsy
absent
*If any 1 of these 3 is abnormal , – Symptoms > 24 hrs
71% stroke probability – Patient not wheel chair
bound or bedridden
– Blood glucose 60-400
– Asymmetry
• Facial smile/ grimace
• Grip
• Arm Strength
 Stroke
• LAPSS :
– rules out other causes of altered level of
consciousness ( hypoglycemia, seizure) then
identify asymmetry
– Sensitivity 93%
– Specificity 97%
 In hospital Stroke care
• Assessment by ED personnel with suspected stroke be done
within 10 minutes.
• Decision for Immediate Cranial CT scan
• Cranial CT scan with in 25 minutes
• CT scan interpretation within 45 minutes
• Fibrinolytic treatment for Ischemic Stroke within 1 hour from
diagnosis
• Control of Blood Pressure
• Decompression
• Temperature control

•
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