Resuscitation

 

Causes of arrest:

H

·      Hypoxia

·      Hypovolaemia

·      Hypothermia

·      Hypo/hyper electrolyes

T

·      Thrombus (AMI, PE)

·      Toxin

·      Tension pneumothorax

·      Tamponade

 

Generic:

Algorithm

Common pathway:

·      CPR 30:2

·      Attach defibrillator

·      Rhythm check

·      1 loop = 5 x 30:2 = 2 mins

Non-shockable pathway:

·      Adrenaline immediately, repeat every second cycle

Shockable pathway:

·      Adrenaline: after 2nd unsuccessful shock, repeat every second cycle

·      Amiodarone: after 3rd unsuccessful shock

·      Lignocaine: if amiodarone not available

1.Chest compressions

·      Start if no pulse or if SBP <60mmHg on A-line

·      Location: lower half of sternum

·      Depth: 1/3 of chest or ≥5cm

·      Rate: 100-120

·      Ratio: 30:2

·      Don’t forget: allow complete relaxation between compressions

·      LUCAS if prolonged

2.Bag mask ventilation

·      100% O2

·      Bag and mask + two hands + guedel

·      Upgrade to LMA: by default

·      Upgrade to ETT: a) if easy b) if important (e.g. drowning)

·      Capnography essential for all of the above

3.Defibrillation

·      200J biphasic

·      Delay <5 seconds after hands off

·      3 stacked shocks only if immediate

4.Drugs

·      Adrenaline: 1mg or 10mcg/kg

·      Amiodarone: 300mg or 5mg/kg

·      Lignocaine: 100mg or 1mg/kg q5mins x 3

·      MgCl2 1-2g over 3 mins

·      CaCl2 10% 10mL or 0.2mL/kg

·      HCO3: 70mL or 1-2mL/kg

5.Other

·      Access: PIVC, A-line

·      Monitoring: SpO2, NIBP, ECG, capno, A-line

·      Investigations: ABG, TTE

 

Post-resuscitation care:

Problems

·      Ischaemia: brain (stroke), heart (↓↓LVEF 24-48h)

·      Trauma: heart, ribs, sternum

·      Reperfusion: multi-organ dysfunction, seizures (beware non-convulsive)

Approach

·      ABCDE

·      Find and treat cause

Aims

·      SBP: >100mmHg

·      O2: 94-98% (↑ = bad)

·      CO2: ?40mmHg (↑ = probably bad, await TAME trial)

·      Temp: 32-36°C for 24h (↑ = bad)

·      BSL: 8-16mM (↓ = bad)

·      Seizure control

 

Team debrief

(adapted from Ned Douglas’ presentation at the Melbourne Part 2 Exam Course)

N.B. compulsory ‘hot’ debrief is often harmful

Introduction

·      Thank you to everyone involved

Events

·      What happened

·      Why did it happen

·      Why was resuscitation stopped

·      Acknowledge uncertainty

Response

·      Discuss adjustment reactions

·      Normalise

·      Encourage self-monitoring

What next

·      Establish referral pathways if distress severe or prolonged (>2/52)

·      Provide mechanism for feedback / concerns / further discussion

 

Paediatrics

Special causes

·      Hypoxia

·      Hypotension

·      Acidosis

·      Rhythm: brady +++ or asystole

What

CPR ratio:

·      Neonate: ratio 3:1

·      Child: 15:2

Per kilo:

·      Adrenaline: 10mcg/kg

·      Amiodarone: 5mg/kg

·      Defibrillation: 4J/kg

 

Pregnancy:

Special causes

·      Obstetric: bleeding, sepsis, thromboembolism (AFE, VTE)

·      Anaesthetic: LAST

·      Rhythm: usually PEA

Why

A&B:

·      Difficult ventilation (↓compliance)

·      Difficult oxygenation (↑shunt, especially supine)

·      Risk of aspiration

C:

·      Supine aortocaval compression

·      Massive extra vascular bed

What

Main thing:

·        Get baby out within 5 mins if >24/40

A&B:

·        Intubate early

·        ICCs higher

C:

·        Manual uterine displacement (better than wedge)

·        CPR higher

·        Defib pads anterior + posterior

·        IV access above the diaphragm

·        Anti-D if Rh-ve

 

Post-cardiac surgery:

Special causes

·      Tamponade

·      Haemothorax

·      Pneumothorax

·      Pacing failure

·      Haemorrhage

When

·      Up to day 10 post-op

·      N.B. survival 80%

What

·      Airway and breathing:

o   Check ETT

o   Check lung fields

·      Circulation:

o   CPR – aim SBP 60mmHg

o   Can delay if pacing/defibrillation imminent

·      Defibrillation:

o   VF/VT: three stacked shocks (success 78%, 35%, 14%)

o   PEA: turn pacing off (may conceal VF/VT)

o   Asystole: turn pacing up – DDD, 88/min, max current

·      Drugs:

o   Stop all infusions, check, restart if ok

o   Atropine 3mg: if bradycardia/asystole (N.B. disagreement)

o   Adrenaline: no

o   Amiodarone 300mg: if stacked shocks unsuccessful

·      Open the chest:

o   Call surgeon ASAP

o   Sternotomy at 5-10mins

o   Internal cardiac massage

o   Internal defibrillation (20J)

 

Chest trauma

Why

·      Bleeding

·      Tamponade

What

·      Bilateral chest compression

·      Early thoracotomy

o  If tamponade: decompress

o  If bleeding: stop it

o  If looks normal: clamp descending aorta

 

Transcutaneous pacing:

Can’t find better place for this at the moment

·        Turn on to pacing mode

·        Place pads for current through heart (left anterior + left posterior chest)

·        Set heart rate at 88

·        Increase current until capture, then a bit more

·        Press the start button (!)