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Resuscitation ABCs William Beaumont Hospital Department of Emergency Medicine.

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1 Resuscitation ABCs William Beaumont Hospital Department of Emergency Medicine

2 What we are covering in a nutshell… Airway Airway Breathing Breathing Circulation and Shock Circulation and Shock

3 Airway: Decision to Intubate Failure to maintain or protect airway Failure to maintain or protect airway Reposition the patient and apply the jaw thrust or chin lift maneuver to open the airway Reposition the patient and apply the jaw thrust or chin lift maneuver to open the airway Failure to ventilate or oxygenate Failure to ventilate or oxygenate Hypoxemia not responding to above maneuvers or application of external O2 Hypoxemia not responding to above maneuvers or application of external O2 Fatigue or tiring out secondary to tachypnea, excessive work of breathing Fatigue or tiring out secondary to tachypnea, excessive work of breathing Anticipate the need for intubation Anticipate the need for intubation Status epilepticus, OD, multiple trauma, sepsis… Status epilepticus, OD, multiple trauma, sepsis…

4 Sniffing Position The sniffing position is achieved by A) Extending the head while A) Extending the head while B) Simultaneously flexing the neck B) Simultaneously flexing the neck Neck flexion is maintained by placing padding behind the head Contraindicated: potential C-spine injury

5 Difficult Intubation: Physical Characteristics Anatomically abnormal facies Anatomically abnormal facies Neck Trauma Neck Trauma Prominent Incisors Prominent Incisors Receding Mandible or Small Jaw Receding Mandible or Small Jaw C-spine immobilization C-spine immobilization Short and thick neck Short and thick neck Large tongue Large tongue

6 Difficult BVM Characteristics Edentulous Edentulous Obesity Obesity History of snoring History of snoring Beards or facial hair Beards or facial hair Facial or neck trauma Facial or neck trauma Obstructive airway disease or bronchospasm Obstructive airway disease or bronchospasm 3 rd trimester pregnancy 3 rd trimester pregnancy

7 Mallampati Signs for Difficult Intubation

8 Comparing Pediatric and Adult Airways Anatomic differences Anatomic differences Small mouth plus proportionately larger soft tissues and structures (tongue and tonsils) Small mouth plus proportionately larger soft tissues and structures (tongue and tonsils) Airway location and vocal cords are higher and more anterior in children Airway location and vocal cords are higher and more anterior in children Most narrow portion of the airway in kids is at the cricoid cartilage – therefore uncuffed ET tubes should be used (adults most narrow below the cricoid at the vocal cords) Most narrow portion of the airway in kids is at the cricoid cartilage – therefore uncuffed ET tubes should be used (adults most narrow below the cricoid at the vocal cords) Pediatric cricothyroid membrane is small, difficult to palpate, and incise so cricothyroidotomy is contraindicated < 8 y/o Pediatric cricothyroid membrane is small, difficult to palpate, and incise so cricothyroidotomy is contraindicated < 8 y/o

9 Comparing Pediatric and Adult Airways Anatomic Differences cont… Anatomic Differences cont… Pediatric trachea is shorter so is more prone to R mainstem intubation and tube dislodgement Pediatric trachea is shorter so is more prone to R mainstem intubation and tube dislodgement Larger occiput causes passive flexion of the c-spine and buckling of the airway -> sniffing position to open the airway and align the axis of the oropharynx/larynx/vocal cords Larger occiput causes passive flexion of the c-spine and buckling of the airway -> sniffing position to open the airway and align the axis of the oropharynx/larynx/vocal cords

10 Pediatric Airway Estimating ET tube size Estimating ET tube size Broselow tape Broselow tape (age+16)/4 (age+16)/4 ETT size estimation based upon the width of the childs fifth fingernail ETT size estimation based upon the width of the childs fifth fingernail

11 Endotracheal Intubation Purpose – to achieve definitive airway control (LMA and combitube are NOT) Purpose – to achieve definitive airway control (LMA and combitube are NOT) Indications Indications Respiratory failure Respiratory failure Airway protection in an unconscious patient Airway protection in an unconscious patient Decrease the work of breathing Decrease the work of breathing Therapeutic interventions such as hyperventilation for HI or to protect the airway during diagnostic studies Therapeutic interventions such as hyperventilation for HI or to protect the airway during diagnostic studies

12 Straight vs Curved Blades Straight Blade Straight Blade Preferred in infants and kids < 8 yo Preferred in infants and kids < 8 yo tip of the blade passes over the epiglottis and tongue to physically lift them out of the way tip of the blade passes over the epiglottis and tongue to physically lift them out of the way Curved Blade Curved Blade Fits into the vallecula between the tongue and epiglottis to lift the palate and soft tissues anteriorly Fits into the vallecula between the tongue and epiglottis to lift the palate and soft tissues anteriorly Mechanically difficult to use in obese adults and children with lots of floppy soft tissue structures Mechanically difficult to use in obese adults and children with lots of floppy soft tissue structures

13 RSI = Rapid Sequence Intubation Definition = systematic protocol using sedatives and paralytics to increase chances of successful intubation and decrease the risk of aspiration (hopefully) Definition = systematic protocol using sedatives and paralytics to increase chances of successful intubation and decrease the risk of aspiration (hopefully) Indications – airway control or compromise, shock, head injury, impending respiratory arrest Indications – airway control or compromise, shock, head injury, impending respiratory arrest Contraindications – physically obstructed airway, severe mid facial fractures, neck or throat surgery or trauma Contraindications – physically obstructed airway, severe mid facial fractures, neck or throat surgery or trauma When to think twice – short, fat bull neck, c spine trauma, oral abscess or masses, ludwigs angina, facial burns When to think twice – short, fat bull neck, c spine trauma, oral abscess or masses, ludwigs angina, facial burns

14 The 6 Ps of RSI 1. Prepare Equipment – suction, blade, ETT, monitor, nursing staff, drugs Equipment – suction, blade, ETT, monitor, nursing staff, drugs 2. Pre Oxygenate Provides a period of time after the patient becomes apneic in which they will remain adequately oxygenated Provides a period of time after the patient becomes apneic in which they will remain adequately oxygenated BVM or 100% O2 for 3-5 minutes BVM or 100% O2 for 3-5 minutes

15 The 6 Ps of RSI 3. Pre Treatment Sedation – opioids, benzos, ketamine, etomidate Sedation – opioids, benzos, ketamine, etomidate Head Injury or Increased ICP – lidocaine, fentanyl, defasciculating dose of paralytic Head Injury or Increased ICP – lidocaine, fentanyl, defasciculating dose of paralytic Atropine for Kids prior to intubation to prevent vagal induced bradycarida Atropine for Kids prior to intubation to prevent vagal induced bradycarida 4. Paralysis Depolarizing Agents = Succinylcholine Depolarizing Agents = Succinylcholine Nondepolarizing Agents = pancuronium, vecuronium, but mostly ROCURONIUM Nondepolarizing Agents = pancuronium, vecuronium, but mostly ROCURONIUM

16 Succinylcholine Mimics Ach at the neuromuscular junction Mimics Ach at the neuromuscular junction Onset of action is seconds Onset of action is seconds Duration is seconds Duration is seconds Dose 1-1.5mg/kg for adults and 1.5-2mg/kg for kids (remember to pre treat with atropine) Dose 1-1.5mg/kg for adults and 1.5-2mg/kg for kids (remember to pre treat with atropine) Side Effects Side Effects histamine release causing hypotension histamine release causing hypotension rise in ICP rise in ICP Release of K from cells – precaution in burn patients, diabetics, patients found down (rhabdo) Release of K from cells – precaution in burn patients, diabetics, patients found down (rhabdo)

17 Nondepolarizing Agents – Rocuronium Reversible, competitive antagonist of Ach at the neuromuscular junction Reversible, competitive antagonist of Ach at the neuromuscular junction Slower onset of action but longer acting Slower onset of action but longer acting Can be reversed (rarely) with edrophonium Can be reversed (rarely) with edrophonium Onset is seconds Onset is seconds Duration is 30 minutes Duration is 30 minutes Dose is mg/kg for adults and kids Dose is mg/kg for adults and kids

18 The 6 Ps of RSI 5. Pass the Tube Assess the depth of paralysis through degree of relaxation of the jaw muscle or eye lids Assess the depth of paralysis through degree of relaxation of the jaw muscle or eye lids Apply cricoid pressure = Sellick Maneuver to prevent aspiration (not maneuvering the trachea) Apply cricoid pressure = Sellick Maneuver to prevent aspiration (not maneuvering the trachea) Visualize the cords Visualize the cords Pass the tube into the trachea Pass the tube into the trachea

19 The 6 Ps of RSI 6. Position Check See the tube pass through the cords See the tube pass through the cords Check for symmetric chest wall rise and fall with bagging Check for symmetric chest wall rise and fall with bagging Check for equal bilateral breath sounds Check for equal bilateral breath sounds End tidal CO2 detection (color change) End tidal CO2 detection (color change) CXR for position of ETT CXR for position of ETT

20 The 6 Ps of RSI Pitfalls – OK this is 7, we made this one up Pitfalls – OK this is 7, we made this one up Not preparing and checking your equipment Not preparing and checking your equipment Forgetting cricoid pressure Forgetting cricoid pressure Over aggressively BVM causing gastric distension and increased risk of aspiration Over aggressively BVM causing gastric distension and increased risk of aspiration

21 Cricothyroidotomy Creation of an opening in the cricothyroid membrane for placement of a trach tube when oral intubation fails or is contraindicated Creation of an opening in the cricothyroid membrane for placement of a trach tube when oral intubation fails or is contraindicated Incidence – 1% of all ED intubations Incidence – 1% of all ED intubations Contraindications (relative) Contraindications (relative) distorted neck anatomy distorted neck anatomy pre existing infection pre existing infection coagulopathy coagulopathy children < 10 years old children < 10 years old

22 Cricothyroidotomy 1. Locate cricothyroid cartilage cm vertical skin incision 3. Horizontal stab thru cricothyroid membrane 4. Insert hemostat & dilate opening horizontally then vertically 5. Insert #4 Shiley trach tube or 5 mm ET tube (cut short) & verify position 6. Inflate balloon & secure tube

23 Questions? Questions? Lets move on to circulation Lets move on to circulation

24 Circulation Shock – a pathologic state that initiates a sequence of stress responses in the body designed to preserve flow to vital organs 4 Types of Shock Hypovolemic - hemorrhagic, nonhemorrhagic Hypovolemic - hemorrhagic, nonhemorrhagic Distributive – septic, anaphylactic, neurogenic Distributive – septic, anaphylactic, neurogenic Cardiogenic – arrhythmias, other – AMI, cardiomyopathy, OD Cardiogenic – arrhythmias, other – AMI, cardiomyopathy, OD Obstructive – tension pneumothorax, cardiac tamponade, pulmonary embolus, ductal dependent Obstructive – tension pneumothorax, cardiac tamponade, pulmonary embolus, ductal dependent

25 Septic Shock Septic shock – patient with sepsis who remains hypotensive (SBP < 90) despite adequate fluid resuscitation Septic shock – patient with sepsis who remains hypotensive (SBP < 90) despite adequate fluid resuscitation Sepsis – patient with presumed or known infection plus 2 or more SIRS criteria Sepsis – patient with presumed or known infection plus 2 or more SIRS criteria SIRS criteria – systemic inflammatory response syndrome SIRS criteria – systemic inflammatory response syndrome 1) temp > 38*C or 38*C or < 36*C 2) HR > 90 bpm 2) HR > 90 bpm 3) RR > 20/ min or PaCo2 20/ min or PaCo2 < 34 4) WBC > 12,000 or 12,000 or < 4,000

26 Septic Shock Pathophysiology Pathophysiology a focus of infection causes release of large amount of toxin a focus of infection causes release of large amount of toxin the body reacts by releasing mediators and humoral defenses such as complement, cytokines, and platelet activating factor the body reacts by releasing mediators and humoral defenses such as complement, cytokines, and platelet activating factor Clinical Features Clinical Features hot flushed skin, hyperthermia or hypothermia, tachycardia, tachypnea, wide pulse pressure, mental status changes hot flushed skin, hyperthermia or hypothermia, tachycardia, tachypnea, wide pulse pressure, mental status changes

27 Septic Shock Therapy Attention to ABCs – assess ventilation and oxygenation Attention to ABCs – assess ventilation and oxygenation Aggressive fluid administration – Normal saline fluid boluses of 20cc/kg Aggressive fluid administration – Normal saline fluid boluses of 20cc/kg may need to repeat 2-3 times until SBP>90 may need to repeat 2-3 times until SBP>90 Empiric antibiotics – cover Gm + and Gm – Empiric antibiotics – cover Gm + and Gm – Lab evaluation – CBC, BMP, U/A, urine & blood cultures, CXR, lactic acid Lab evaluation – CBC, BMP, U/A, urine & blood cultures, CXR, lactic acid

28 Septic Shock Pressors Pressors Norepinephrine - first line drug Norepinephrine - first line drug 2-20 mcg/kg/min 2-20 mcg/kg/min Dopamine – may add to norepinephrine or change to this based on clinical response Dopamine – may add to norepinephrine or change to this based on clinical response 5-20 mcg/kg/min 5-20 mcg/kg/min Vasopressin – should not be sole agent Vasopressin – should not be sole agent Phenylephrine – used in patients with excessive tachycardia from pressors Phenylephrine – used in patients with excessive tachycardia from pressors Consider steroids Consider steroids sepsis associated with adrenal insufficiency sepsis associated with adrenal insufficiency hydrocortisone 100mg IVP or hydrocortisone 100mg IVP or dexamethazone 4 mg IVP dexamethazone 4 mg IVP

29 Hemorrhagic Shock Defined – blood loss of significant magnitude to overcome normal physiologic compensatory response and compromise tissue perfusion Defined – blood loss of significant magnitude to overcome normal physiologic compensatory response and compromise tissue perfusion Blood loss triggers increased cardiac rate & force of contraction Blood loss triggers increased cardiac rate & force of contraction To maintain BP, redistribution of blood flow occurs to preserve vital organ function, conserve water and sodium, and control blood loss. To maintain BP, redistribution of blood flow occurs to preserve vital organ function, conserve water and sodium, and control blood loss. Baroreceptors sense fall in BP and release norepinephrine. Baroreceptors sense fall in BP and release norepinephrine. Norepinephrine increases CO and stimulates renin secretion (increasing Na & H2O reabsorption) Norepinephrine increases CO and stimulates renin secretion (increasing Na & H2O reabsorption)

30 Hemorrhagic Shock Norepinephrine causes vasoconstriction especially in the splanchnic blood vessels which can increase circulating blood volume by 20-30% Norepinephrine causes vasoconstriction especially in the splanchnic blood vessels which can increase circulating blood volume by 20-30% Acute hemorrhage also causes local activation of the clotting cascade so blood vessels contract and plateletes adhere to damaged vessels. Acute hemorrhage also causes local activation of the clotting cascade so blood vessels contract and plateletes adhere to damaged vessels.

31 Hemorrhagic Shock Skin cool, clammy, mottled Tachycardia, narrow pulse pressure RR > 22 PaCo2 22 PaCo2 < 32 Site of hemorrhage not always obvious Treatment Control hemorrhage Control hemorrhage Rapid infusion of several liters NS in adults or successive 20cc/kg boluses in kids Rapid infusion of several liters NS in adults or successive 20cc/kg boluses in kids If still hypotensive after aggressive fluid resuscitation, then transfuse 5-10 ml/kg PRBC type specific If still hypotensive after aggressive fluid resuscitation, then transfuse 5-10 ml/kg PRBC type specific If uncontrolled hemorrhage, then use uncrossmatched blood (type O neg) If uncontrolled hemorrhage, then use uncrossmatched blood (type O neg)

32 Hemorrhagic Shock Class 1 – 15% loss – mild tachycardia only, rapid response to fluids Class 1 – 15% loss – mild tachycardia only, rapid response to fluids Class 2 – 15-30% loss – PP ( DBP and PVR), subtle MS changes, cap refill > 2 s Class 2 – 15-30% loss – PP ( DBP and PVR), subtle MS changes, cap refill > 2 s Class 3 – 30-40% loss – SBP, marked MS changes, transient response to IVF Class 3 – 30-40% loss – SBP, marked MS changes, transient response to IVF Class 4 - > 2 L loss – obtunded, clammy, marked hypotension, narrow PP, minimal or no response to IVF – needs blood Class 4 - > 2 L loss – obtunded, clammy, marked hypotension, narrow PP, minimal or no response to IVF – needs blood

33 CARDIOGENIC SHOCK Definition: results when >40% myocardial necrosis from ischemia, inflammation or toxins Definition: results when >40% myocardial necrosis from ischemia, inflammation or toxins Primary cause – pump failure Primary cause – pump failure Cardiogenic shock produces same circulatory and metabolic alterations as hemorrhagic shock Cardiogenic shock produces same circulatory and metabolic alterations as hemorrhagic shock Clinical Clinical distended neck veins imply CHF, PE, tamponade distended neck veins imply CHF, PE, tamponade muffled heart tones think tamponade muffled heart tones think tamponade fever & new murmur – endocarditis fever & new murmur – endocarditis loud machine like murmur – papillary muscle rupture loud machine like murmur – papillary muscle rupture asymmetric breath sounds – pneumothorax asymmetric breath sounds – pneumothorax Becks triad (pericardial tamponade)– JVD, hypotension, muffled heart tones Becks triad (pericardial tamponade)– JVD, hypotension, muffled heart tones

34 CARDIOGENIC SHOCK TREATMENT TREATMENT O2, PEEP for CHF, O2, PEEP for CHF, intubate for impending respiratory failure intubate for impending respiratory failure Inotropic support - dobutamine, dopamine Inotropic support - dobutamine, dopamine Treat underlying cause – AMI, PE Treat underlying cause – AMI, PE Inamrinone (Inocor) for refractory hypotension, may improve CO by increasing cAMP, no tachyphylaxis and no increased myocardial O2 consumption Inamrinone (Inocor) for refractory hypotension, may improve CO by increasing cAMP, no tachyphylaxis and no increased myocardial O2 consumption Consider aortic balloon pump – improves diastolic coronary perfusion and cardiac output by 30% Consider aortic balloon pump – improves diastolic coronary perfusion and cardiac output by 30%

35 ANAPHYLACTIC SHOCK Results from IgE mediated systemic response to an allergen Results from IgE mediated systemic response to an allergen IgE causes mast cells to release histamine resulting in vasodilation, bronchoconstriction, capillary leak into interstitial space IgE causes mast cells to release histamine resulting in vasodilation, bronchoconstriction, capillary leak into interstitial space Clinical – the quicker the symptoms manifest, the more severe the reaction Clinical – the quicker the symptoms manifest, the more severe the reaction Symptoms - flushing, warmth, urticaria, pruritis, dyspnea, wheezing, angioedema, tachycardia, tachypnea, hypotension Symptoms - flushing, warmth, urticaria, pruritis, dyspnea, wheezing, angioedema, tachycardia, tachypnea, hypotension

36 Anaphylactic Shock Therapy Benadryl/Cimetadine – H1 H2 blockers Benadryl/Cimetadine – H1 H2 blockers prevent urticaria, reduce bronchoconstriction, reduce fluid transudation prevent urticaria, reduce bronchoconstriction, reduce fluid transudation Corticosteroids Corticosteroids Nebulized B2 agonist – reduce bronchospasm Nebulized B2 agonist – reduce bronchospasm Epinephrine Epinephrine alpha agonist – reverses hypotension by vasoconstriction alpha agonist – reverses hypotension by vasoconstriction beta agonist – bronchodilation, positive ionotrope and chronotrope beta agonist – bronchodilation, positive ionotrope and chronotrope stop T cell and mast cell activation stop T cell and mast cell activation reduce bronchial inflammation reduce bronchial inflammation

37 CENTRAL NEUROGENIC SHOCK Definition – loss of neurologic function and autonomic tone below the level of the spinal cord lesion Definition – loss of neurologic function and autonomic tone below the level of the spinal cord lesion Hypotension from spinal shock is a diagnosis Hypotension from spinal shock is a diagnosis of exclusion in the trauma patient. of exclusion in the trauma patient. It is caused by loss of vasomotor tone and lack of reflex tachycardia from disruption of autonomic ganglia. It is caused by loss of vasomotor tone and lack of reflex tachycardia from disruption of autonomic ganglia. Clinical – flaccid paralysis, loss of DTRs, loss of bladder tone, bradycardia, hypotension, hypothermia, skin warm & dry, good urine output Clinical – flaccid paralysis, loss of DTRs, loss of bladder tone, bradycardia, hypotension, hypothermia, skin warm & dry, good urine output

38 Central Neurogenic Shock Treatment Treatment Adequate fluid replacement Adequate fluid replacement Atropine – treat vagal mediated bradycardia Atropine – treat vagal mediated bradycardia Ephedrine/Phenylephrine – promote vasoconstriction and promote cord perfusion Ephedrine/Phenylephrine – promote vasoconstriction and promote cord perfusion Methylprednisolone - given w/in 8 hrs of injury shown to improve neurologic recovery Methylprednisolone - given w/in 8 hrs of injury shown to improve neurologic recovery

39 BURNS Fluid Resuscitation Fluid Resuscitation Parkland Formula for Burns Parkland Formula for Burns 4ml/kg x (% BSA burned) 4ml/kg x (% BSA burned) give ½ of fluid in first 8 hours give ½ of fluid in first 8 hours Rule of Nines Rule of Nines Technique for estimating the extent Technique for estimating the extent of body surface area burned of body surface area burned The difference between the BSA of an adult and an infant reflects the size of the infants head an infant reflects the size of the infants head which is proportionately larger than an adult. which is proportionately larger than an adult.

40 RULE OF NINES Diagram #5

41 PEDIATRIC RESUSCITATION DOSES Defibrillation 2J/kg then 4J/kg, 4J/kg Defibrillation 2J/kg then 4J/kg, 4J/kg Epinephrine.01mg/kg (1:10,000) Epinephrine.01mg/kg (1:10,000) Atropine.01mg/kg Atropine.01mg/kg GlucoseD10 2-4ml/kg (not D50) GlucoseD10 2-4ml/kg (not D50) Fluid ml/kg NS bolus Fluid ml/kg NS bolus Drugs you can give thru an ET tube (NAVEL) Drugs you can give thru an ET tube (NAVEL) Narcan Atropine Valium Epi Lidocaine Narcan Atropine Valium Epi Lidocaine

42 HYPERKALEMIA K level EKG changes 5.6 – 6.0 tall peaked T waves 5.6 – 6.0 tall peaked T waves 6.0 – 7.0 long PR & QT 6.0 – 7.0 long PR & QT decreased P waves decreased P waves ST segment depression ST segment depression 7.0 – 8.0 idioventricular rhythm 7.0 – 8.0 idioventricular rhythm wide QRS wide QRS 10.0 and up sine wave

43

44 HYPERKALEMIA

45 TREATMENT OF HYPERKALEMIA Kayexalate Kayexalate ion exchange resin given po or pr ion exchange resin given po or pr each gram exchanges with & eliminates 1mEq K each gram exchanges with & eliminates 1mEq K Insulin/Glucose/HCO3 – use if EKG changes or Insulin/Glucose/HCO3 – use if EKG changes or unstable unstable glucose enters cells & pulls K with it glucose enters cells & pulls K with it dose: Insulin 10 U IV, Glucose 1 amp D50, 1 amp HCO3 dose: Insulin 10 U IV, Glucose 1 amp D50, 1 amp HCO3 Ca gluconate/ Ca Cl – use if hypotension, CP, SOB, Ca gluconate/ Ca Cl – use if hypotension, CP, SOB, lethargy, coma lethargy, coma 10ml of 10% Ca Cl (1 amp) slowly over min 10ml of 10% Ca Cl (1 amp) slowly over min if patient on Digoxin, be very cautious – Calcium potentiates toxic effects of digoxin on the heart if patient on Digoxin, be very cautious – Calcium potentiates toxic effects of digoxin on the heart

46 THE END


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