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ACLS Special Resuscitations Dr. Michelle Welsford.

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1 ACLS Special Resuscitations Dr. Michelle Welsford

2 Introduction tHypothermia tTraumatic Cardiac Arrest tElectrical Shock and Lightning tCardiac Arrest associated with Pregnancy tToxicologic Cardiac Emergencies

3 Hypothermia tSevere hypothermia: T < 30C tOften unresponsive to defibrillation and pacemaker t  CBF and O2 requirement,  Cardiac Output,  arterial pressure tmay appear clinically dead because CNS depression and CVS depression

4 Hypothermia Continued tPeripheral pulses and respiration may be difficult to detect tTake 30-45 seconds to confirm pulselessness or profound bradycardia tBradycardia is usually physiologic and pacing not indicated until warmed tV fibrillation –Try 3 shocks but may be unsuccessful until rewarmed –Can repeat defib when temperature rises > 32 C

5 Hypothermia Continued tHandle gently to avoid precipitating v. fib tIntubate gently; Avoid NG, pacer, etc tWarming –“warm and dead” – try to rewarm to 34 C but use judgment –if dead – wont’ be able to warm completely –External warming –Internal warming

6 Hypothermia Continued tMetabolism of medications is slowed –< 30 C - only one round of medications –> 30 C usual meds but at greater intervals –Bretylium – ? DOC in hypothermic V fib because raises fibrillation threshold

7 Traumatic Cardiac Arrest tDon’t need to begin resuscitation if: –Hemicorporectomy –Decapitation –Total body burns –Obvious severe blunt trauma without vital signs –Deep penetrating cranial injuries –Penetrating injuries, asystole and transfer time > 15 minutes to trauma centre

8 Blunt Trauma Cardiac Arrest tExsanguinations often difficult to treat tSurvival nearly nil except: –Ventilate high spinal cord injury –Clear Airway obstruction –Relief of Tension pneumo –Fluid/Blood resuscitation of single organ injury –Defibrillation of VF that may have caused trauma

9 Penetrating Trauma Arrest tDirectly to trauma centre if < 15 minutes from arrest tIntubation tIV en-route tIn general, don’t worry about meds/defib tRapid fluid resuscitation after control of hemorrhage surgically

10 Electrical Shock & Lightning tAlternating current: –Ventricular fibrillation common tDirect current: –Asystole common

11 Electrical Shock & Lightning Continued tRespiratory arrest may be prolonged long after cardiac rhythm restored tRespiratory arrest secondary to: –Inhibition of central medullary respiratory centre –Tetanic contraction of the diaphragm and chest wall musculature during current exposure –Prolonged paralysis of respiratory muscles tWith electic/lightning injuries - use reverse triage and treat nonbreathing, pulseless patients first

12 Electrical Shock & Lightning Continued tManagement: –Ensure safety –CPR –young, healthy people may have good survival even after as long as 1 hour of CPR –Ventilation –Treat burns: Lightning: rarely have cutaneous/muscle injury Electric: often have cutaneous burns, muscle, etc –Myoglobinuria will require fluid resuscitation +/- bicarbonate

13 Cardiac Arrest in Pregnancy tPhysiologic changes in pregnancy –  Maternal CO by up to 50% –  HR, minute ventilation, O2 consumption –  Pulmonary functional residual capacity, systemic and pulmonary vascular resistance –less tolerant to respiratory and cardiovascular insults –when supine, gravid uterus may compress inferior vena cava and abdominal aorta resulting in hypotension and  in CO (by 25%)

14 Cardiac Arrest in Pregnancy Continued tPrecipitants of cardiac arrest: –pulmonary embolus –amniotic fluid embolus –trauma –peripartum hemorrhage –congenital and acquired cardiac disease –complications of tocolytic therapy including arrhythmia, CHF, AMI

15 Cardiac Arrest in Pregnancy Continued tManagement: –standard resuscitation followed –if VF then defibrillation –CPR as usual, Meds as usual –Wedge under Right hip to displace uterus to left

16 Cardiac Arrest in Pregnancy Continued tPotential fetal viability up to 20 minutes, best if < 5 minutes tIf no maternal response within 4 minutes, then should consider perimortem C-section (if in neonatal center) tDelivery within 4-5 minutes of arrest tMay result in viable fetus/infant; best survival for mother

17 Toxicologic Cardiac Emergencies – Cocaine tPhysiology: –Stimulates release and blocks reuptake of NE, E, dopamine and serotonin –  BP,  HR, euphoria, CNS stimulation,  myocardial contractility, coronary artery spasm, seizures, death –  coronary artery flow due to spasm and  O2 consumption leading to cardiac ischemia HTN and SVT

18 Cocaine Continued tManagement: –HTN O2 and diazepam, nitro/nitroprusside, Labetalol; not B-blockers! –PSVT, A fib, A flutter O2 (don’t usually require treatment because short- lived) if persistent, often responds to benzos eg: Diazepam: blunts hypersympathetic state centrally

19 Cocaine Continued tventricular irritability –runs of VT, PVCs –O2, benzos, lidocaine, B-blocker –often transient but may require benzos if continue eg: VT –standard ACLS with LIDO but may increase risk of seizures –selective B 1 -blockers may be better (esmolol)

20 Cocaine Continued tVentricular fibrillation –Standard ACLS except increase interval between epi and avoid high dose epi –Lidocaine 1 dose only –If non-responsive try selective B-blocker –Magnesium

21 Cocaine Continued tAMI –Treat with benzodiazepines and nitroglycerin –B-blockade causes unopposed alpha stimulation so avoid –Ischemia/infarction may be due to spasm, therefore angioplasty may be better than thrombolysis

22 Toxicologic Cardiac Emergencies – TCAs tOne of the most cardiotoxic medications tSinus tach, prolonged QT widened QRS, hypotension, ventricular arrhythmias, VT, torsades, seizures tManagement: –Alkalinization:Ph 7.45-7.55 with bolus NaHCO3 –Decrease free unbound form and overrides the Na- channel blockade of phase I action potential –Avoid procainamide; may use lidocaine if necessary (true VT)

23 Summary tACLS guidelines for majority of arrhythmias and resuscitations tSome special resuscitations require deviation from guidelines

24 Questions ?

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