Disclosure Crashing Patient (Beyond A-B-C and ACLS) I have no - PDF document

10 Things You Must Consider in the Disclosure Crashing Patient (Beyond A-B-C and ACLS) I have no financial relationships to disclose. Amal Mattu, MD, FAAEM, FACEP Professor and Vice-Chair Department of Emergency Medicine University of Maryland School of Medicine Baltimore, Maryland Case Presentation Case Presentation • 55 yo man BIBA for not feeling well • No complaints of pain • Awake, diaphoretic, looks sick • VS: Afeb, 100, 28, 85/40, 96%, FS 120 A-B-C LABS • IV, oxygen, monitor, ECG (NSJ) • A-B-C ’ s ~ okay, need some work • What ’ s next? • Give me data! • CBC, chem-50, U/A, BNP, D-dimer, ESR…

Case Presentation Case Presentation A-B-C LABS A-B-C LABS Case Presentation 10 Things You Must Consider in the Crashing Patient (Beyond A-B-C and ACLS) A-B-C LABS Amal Mattu, MD, FAAEM, FACEP Professor and Vice-Chair Department of Emergency Medicine University of Maryland School of Medicine Baltimore, Maryland

10 Things You Must Consider in the Crashing Patient (Beyond A-B-C and ACLS) Amal Mattu, MD, FAAEM, FACEP Director, Emergency Medicine Residency Program Professor, Department of Emergency Medicine University of Maryland School of Medicine Baltimore, Maryland A A B B C C D D E E

A orta A orta Aortic Disasters Aortic Disasters A A B B Non-traumatic Aortic Dissection or B B Rupture As a Cause of Cardiac C C Arrest: Presentation and Outcome (Meron, Resuscitation 2004) C C D D D D E E E E A orta A orta Aortic Disasters Aortic Disasters A A B B Non-traumatic Aortic Dissection or • Majority of patients presented B B Rupture As a Cause of Cardiac without prior complaint of pain C C Arrest: Presentation and Outcome – AAA: only 52% c/o abdominal pain, 32% c/o flank pain (Meron, Resuscitation 2004) C C – TAD: only 48% c/o of chest pain • Evaluated patients from a cardiac D D arrest registry (Austria) that died of D D either aortic dissection or rupture E E • Atypical presentations were common E E

A orta A orta Aortic Disasters Aortic Disasters A A B B • Majority of patients presented • U/S or ECHO (when used) was B B without prior complaint of pain almost always diagnostic! C C – AAA: only 52% c/o abdominal pain, – TAD  pericardial effusion 32% c/o flank pain – AAA  large aorta C C – TAD: only 48% c/o of chest pain D D • Most common presenting rhythm was D PEA (70%) D E E E E A orta A orta Aortic Disasters Aortic Disasters A A B B • Takeaway points: • 65 yo man hemodynamically unstable B B – Always consider TAD and AAA in all – No abdominal or back pain! C C unstable or arresting patients – Routinely perform U/S (for large C C pericardial effusion, AAA) in all D D unstable or arresting patients… • Regardless of whether they report AP, BP D D or CP E E E E

A orta A orta Acid! Acidosis A cid A cidosis B B • Case presentation B B – 58 yo nursing home patient presents C C with decreased LOC – Febrile, dehydrated, hypotensive, RR C C 30, HR 120 D D – HCO 3 10, pH 7.15, pCO 2 18 – Fluids, ABX, etc. etc….patient tiring and D D looks sick… E E – Decision made to intubate… E E A orta A orta Acidosis Acidosis A cidosis A cidosis B B • RSI  no problem! • …but then… B • Vent: AC 15, TV 450, FiO 2 100%... B C C C C D D D D E E E E

A orta A orta Acidosis Acidosis A cidosis A cidosis B B • …but then… • So what went wrong??? B B C C C C D D D D E E E E A orta A orta Acidosis Acidosis A cidosis A cidosis B B • So what went wrong??? • Understanding metabolic acidosis B B C C C C D D D D E E E E

A orta A orta Acidosis Acidosis A cidosis A cidosis B B • Primary metabolic acidosis • Primary metabolic acidosis induces… B B – DKA and the rest of MUDPILES • Compensatory respiratory alkalosis C C – Sepsis (primary M.Ac. + primary and – i.e. hyperventilation improves pH compensatory R.Alk.) C • If you remove the respiratory C – Aspirin OD (primary M.Ac + primary and compensation (e.g. narcotics, RSI)… compensatory R.Alk.) D D • Beware intubation! But if you do… – You induce precipitous fall in pH  D D • Use a higher RR than normal… • Cardiac arrest! E E • But beware the bagging rate if in CA or hypovolemic! E E A orta A orta Bagging/Breathing Bagging/Breathing A cidosis A cidosis B agging B agging • What ’ s the problem with bagging/ Hyperventilation During Cardiac Arrest B B breathing fast (hyperventilating) in (Pitts, Lancet 2004) C C cardiac arrest patients?? Hyperventilation-Induced Hypotension C C During Cardiopulmonary Resuscitation D D (Aufderheide, Circulation 2004) D D E E E E

A orta A orta Bagging/Breathing Bagging/Breathing A cidosis A cidosis B agging B agging • Background • What ’ s the problem with B B hyperventilation? – Resuscitation guidelines recommend C C only 8-10 breaths/min (2010) C C D D D D E E E E A orta A orta Bagging/Breathing Bagging/Breathing A cidosis A cidosis B agging B agging • What ’ s the problem with • What ’ s the problem with B B hyperventilation? hyperventilation? C C – Increases intrathoracic pressure  – Increases intrathoracic pressure  • Decreased preload  decreased cardiac • Decreased preload  decreased cardiac C C output  decreased coronary perfusion output  decreased coronary perfusion D D – Cerebral vasoconstriction  decreased cerebral blood flow D D E E E E

A orta A orta Bagging/Breathing Bagging/Breathing A cidosis A cidosis B agging B agging • What ’ s the problem with • AHA CPR guidelines B B hyperventilation? – De-emphasize importance of bagging/ C C rescue breathing – Increases intrathoracic pressure  • Often too fast  compromises circulation • Decreased preload  decreased cardiac C C output  decreased coronary perfusion • Limits chest compressions D D – Cerebral vasoconstriction  decreased cerebral blood flow D D – Studies demonstrate decreased survival E E rates with excessive ventilation rates E E A orta A orta Bagging/Breathing Bagging/Breathing A cidosis A cidosis B agging B agging • AHA CPR guidelines • Pre-hospital and in-hospital care B B providers routinely hyperventilate – De-emphasize importance of bagging/ C C patients during acute resuscitations rescue breathing • Often too fast  compromises circulation – (Even after retraining!) C C • Limits chest compressions D D – Probably not needed in first 5-10 minutes after primary cardiac arrest D D • Initial central O 2 saturation is fine! E E E E

A orta A orta Bagging/Breathing Bagging/Breathing A cidosis A cidosis B agging B agging • Takeaway points • Takeaway points B B – Avoid hyperventilating pt. during CPR – Avoid hyperventilating pt. during CPR C C – Avoid hyperventilating pt. in overt shock – Avoid hyperventilating pt. in overt shock – Avoid hyperventilation before, during, or – Avoid hyperventilation before, during, or C C after ETI (unless a specific reason to) after ETI (unless a specific reason to) D D • Be certain patient is not hypovolemic • Be certain patient is not hypovolemic – Be aware of the person performing D D BVM…tell them to slow down!! E E – First few minutes of primary CA  no E E positive pressure ventilations!

A orta A orta Baby on Board?? Baby on Board?? A cidosis A cidosis B agging B agging • Crashing/arresting female… B aby?? B aby?? – Always consider ruptured ectopic C C pregnancy – Paradoxical bradycardia common (lack of C C tachycardia with significant blood loss) D D D D E E E E A orta A orta Baby on Board?? Baby on Board?? A cidosis A cidosis B agging B agging • Crashing/arresting female… • Case Presentation B aby?? B aby?? – Always consider ruptured ectopic – 24 yo woman is 30 weeks pregnant C C pregnancy – Presents with ventricular dysrhythmia – Paradoxical bradycardia common (lack of – Hemodynamically stable C C tachycardia with significant blood loss) – How do you treat her? D D – Get the U/S! – What if she were unstable? D D E E E E

A orta A orta Baby on Board?? Baby on Board?? A cidosis A cidosis B agging B agging • Dysrhythmias • Dysrhythmias B aby?? B aby?? – Amiodarone? C C C C D D D D E E E E A orta A orta Baby on Board?? Baby on Board?? A cidosis A cidosis B agging B agging • Dysrhythmias • Electricity…??? B aby?? B aby?? – Amiodarone should be avoided in C C pregnancy • The only class D antidysrhythmic C C • Risk of fetal hypothyroidism, IUGR, fetal bradycardia, prematurity D D • Only rec ’ d if other drugs fail D D – Procainamide, lidocaine preferred for E ventricular dysrhythmias E E E