1. ABCs William Beaumont Hospital Department of Emergency Medicine
Resuscitation
ABCs
William Beaumont Hospital
Department of Emergency Medicine

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

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

4. Sniffing Position The sniffing position is achieved by
A) Extending the head while
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
Neck Trauma
Prominent Incisors
Receding Mandible or Small Jaw
C-spine immobilization
Short and thick neck
Large tongue

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

7. Mallampati Signs for Difficult Intubation
I – entire tonsillar pillars seen; 2- upper tonsils seen 3; hard and soft palate seen; 4; only hard palate seen

8. Comparing Pediatric and Adult Airways
Anatomic differences
Small mouth plus proportionately larger soft tissues and structures (tongue and tonsils)
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)
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…
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

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

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

12. Straight vs Curved Blades
Straight Blade
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
Curved Blade
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

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)
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
When to think twice – short, fat bull neck, c spine trauma, oral abscess or masses, ludwig’s angina, facial burns

14. The 6 P’s of RSI 1. Prepare 2. Pre Oxygenate
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
BVM or 100% O2 for 3-5 minutes

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

16. Succinylcholine Mimics Ach at the neuromuscular junction
Onset of action 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)
Side Effects
histamine release causing hypotension
rise in ICP
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
Slower onset of action but longer acting
Can be reversed (rarely) with edrophonium
Onset is seconds
Duration is 30 minutes
Dose is mg/kg for adults and kids

18. The 6 P’s of RSI 5. Pass the Tube
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)
Visualize the cords
Pass the tube into the trachea

19. The 6 P’s of RSI 6. Position Check See the tube pass through the cords
Check for symmetric chest wall rise and fall with bagging
Check for equal bilateral breath sounds
End tidal CO2 detection (color change)
CXR for position of ETT
Normal tube position cm at the teeth (tube size x 3)

20. The 6 P’s of RSI Pitfalls – OK this is 7, we made this one up
Not preparing and checking your equipment
Forgetting cricoid pressure
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
Incidence – 1% of all ED intubations
Contraindications (relative)
distorted neck anatomy
pre existing infection
coagulopathy
children < 10 years old

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

23. Questions?
Let’s 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
Distributive – septic, anaphylactic, neurogenic
Cardiogenic – arrhythmias, other – AMI, cardiomyopathy, OD
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
Sepsis – patient with presumed or known infection plus 2 or more SIRS criteria
SIRS criteria – systemic inflammatory response syndrome
1) temp > 38*C or < 36*C
2) HR > 90 bpm
3) RR > 20/ min or PaCo2 < 34
4) WBC > 12,000 or < 4,000

26. Septic Shock Pathophysiology
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
Clinical Features
hot flushed skin, hyperthermia or hypothermia, tachycardia, tachypnea, wide pulse pressure, mental status changes

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

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

29. Hemorrhagic Shock
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
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.
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%
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 > PaCo2 < 32
Site of hemorrhage not always obvious
Treatment
Control hemorrhage
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 uncontrolled hemorrhage, then use uncrossmatched blood (type O neg)

32. Hemorrhagic Shock
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 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

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

34. CARDIOGENIC SHOCK TREATMENT O2, PEEP for CHF,
intubate for impending respiratory failure
Inotropic support - dobutamine, dopamine
Treat underlying cause – AMI, PE
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%

35. ANAPHYLACTIC SHOCK
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
Clinical – the quicker the symptoms manifest, the more severe the reaction
Symptoms - flushing, warmth, urticaria, pruritis, dyspnea, wheezing, angioedema, tachycardia, tachypnea, hypotension

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

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

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

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

40. RULE OF NINES
Diagram #5                                            

41. PEDIATRIC RESUSCITATION DOSES
Defibrillation J/kg then 4J/kg, 4J/kg
Epinephrine mg/kg (1:10,000)
Atropine mg/kg
Glucose D10 2-4ml/kg (not D50)
Fluid ml/kg NS bolus
Drugs you can give thru an ET tube (NAVEL)
Narcan Atropine Valium Epi Lidocaine

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

44. HYPERKALEMIA

45. TREATMENT OF HYPERKALEMIA
Kayexalate
ion exchange resin given po or pr
each gram exchanges with & eliminates 1mEq K
Insulin/Glucose/HCO3 – use if EKG changes or
unstable
glucose enters cells & pulls K with it
dose: Insulin 10 U IV, Glucose 1 amp D50, 1 amp HCO3
Ca gluconate/ Ca Cl – use if hypotension, CP, SOB,
lethargy, coma
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

46. THE END