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

Mar 09, 2023 194 likes •551 views

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

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SLIDE 1

10 Things You Must Consider in the

Crashing Patient

(Beyond A-B-C and ACLS)

Amal Mattu, MD, FAAEM, FACEP

Professor and Vice-Chair Department of Emergency Medicine University of Maryland School of Medicine Baltimore, Maryland

Disclosure

I have no financial relationships to disclose.

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
  • 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

A-B-C LABS

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SLIDE 2

Case Presentation

A-B-C LABS

Case Presentation

A-B-C LABS

Case Presentation

A-B-C LABS

10 Things You Must Consider in the

Crashing Patient

(Beyond A-B-C and ACLS)

Amal Mattu, MD, FAAEM, FACEP

Professor and Vice-Chair Department of Emergency Medicine University of Maryland School of Medicine Baltimore, Maryland

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SLIDE 3

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

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SLIDE 4

Aortic Disasters

Aorta A B B C C D D E E

Aortic Disasters

Non-traumatic Aortic Dissection or Rupture As a Cause of Cardiac Arrest: Presentation and Outcome (Meron, Resuscitation 2004)

A B B C C D D E E Aorta

Aortic Disasters

Non-traumatic Aortic Dissection or Rupture As a Cause of Cardiac Arrest: Presentation and Outcome (Meron, Resuscitation 2004)

  • Evaluated patients from a cardiac

arrest registry (Austria) that died of either aortic dissection or rupture

  • Atypical presentations were common

A B B C C D D E E Aorta

Aortic Disasters

  • Majority of patients presented

without prior complaint of pain

– AAA: only 52% c/o abdominal pain, 32% c/o flank pain – TAD: only 48% c/o of chest pain

A B B C C D D E E Aorta

slide-5
SLIDE 5

Aortic Disasters

  • Majority of patients presented

without prior complaint of pain

– AAA: only 52% c/o abdominal pain, 32% c/o flank pain – TAD: only 48% c/o of chest pain

  • Most common presenting rhythm was

PEA (70%)

A B B C C D D E E Aorta

Aortic Disasters

  • U/S or ECHO (when used) was

almost always diagnostic!

– TAD  pericardial effusion – AAA  large aorta

A B B C C D D E E Aorta

Aortic Disasters

  • Takeaway points:

– Always consider TAD and AAA in all unstable or arresting patients – Routinely perform U/S (for large pericardial effusion, AAA) in all unstable or arresting patients…

  • Regardless of whether they report AP, BP
  • r CP

A B B C C D D E E Aorta

Aortic Disasters

  • 65 yo man hemodynamically unstable

– No abdominal or back pain!

A B B C C D D E E Aorta

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SLIDE 6

Acid!

Aorta Acid B B C C D D E E

Acidosis

  • Case presentation

– 58 yo nursing home patient presents with decreased LOC – Febrile, dehydrated, hypotensive, RR 30, HR 120 – HCO3 10, pH 7.15, pCO2 18 – Fluids, ABX, etc. etc….patient tiring and looks sick… – Decision made to intubate…

Aorta Acidosis B B C C D D E E

Acidosis

  • RSI  no problem!
  • Vent: AC 15, TV 450, FiO2 100%...

Aorta Acidosis B B C C D D E E

Acidosis

  • …but then…

Aorta Acidosis B B C C D D E E

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SLIDE 7

Acidosis

  • …but then…

Aorta Acidosis B B C C D D E E

Acidosis

  • So what went wrong???

Aorta Acidosis B B C C D D E E

Acidosis

  • So what went wrong???

Aorta Acidosis B B C C D D E E

Acidosis

  • Understanding metabolic acidosis

Aorta Acidosis B B C C D D E E

slide-8
SLIDE 8

Acidosis

  • Primary metabolic acidosis induces…
  • Compensatory respiratory alkalosis

– i.e. hyperventilation improves pH

  • If you remove the respiratory

compensation (e.g. narcotics, RSI)…

– You induce precipitous fall in pH 

  • Cardiac arrest!

Aorta Acidosis B B C C D D E E

Acidosis

  • Primary metabolic acidosis

– DKA and the rest of MUDPILES – Sepsis (primary M.Ac. + primary and compensatory R.Alk.) – Aspirin OD (primary M.Ac + primary and compensatory R.Alk.)

  • Beware intubation! But if you do…
  • Use a higher RR than normal…
  • But beware the bagging rate if in CA
  • r hypovolemic!

Aorta Acidosis B B C C D D E E

Bagging/Breathing

  • What’s the problem with bagging/

breathing fast (hyperventilating) in cardiac arrest patients??

Aorta Acidosis Bagging B C C D D E E

Bagging/Breathing

Hyperventilation During Cardiac Arrest (Pitts, Lancet 2004) Hyperventilation-Induced Hypotension During Cardiopulmonary Resuscitation (Aufderheide, Circulation 2004)

Aorta Acidosis Bagging B C C D D E E

slide-9
SLIDE 9

Bagging/Breathing

  • Background

– Resuscitation guidelines recommend

  • nly 8-10 breaths/min (2010)

Aorta Acidosis Bagging B C C D D E E

Bagging/Breathing

  • What’s the problem with

hyperventilation?

Aorta Acidosis Bagging B C C D D E E

Bagging/Breathing

  • What’s the problem with

hyperventilation?

– Increases intrathoracic pressure 

  • Decreased preload  decreased cardiac
  • utput  decreased coronary perfusion

Aorta Acidosis Bagging B C C D D E E

Bagging/Breathing

  • What’s the problem with

hyperventilation?

– Increases intrathoracic pressure 

  • Decreased preload  decreased cardiac
  • utput  decreased coronary perfusion

– Cerebral vasoconstriction  decreased cerebral blood flow

Aorta Acidosis Bagging B C C D D E E

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SLIDE 10

Bagging/Breathing

  • What’s the problem with

hyperventilation?

– Increases intrathoracic pressure 

  • Decreased preload  decreased cardiac
  • utput  decreased coronary perfusion

– Cerebral vasoconstriction  decreased cerebral blood flow – Studies demonstrate decreased survival rates with excessive ventilation rates

Aorta Acidosis Bagging B C C D D E E

Bagging/Breathing

  • AHA CPR guidelines

– De-emphasize importance of bagging/ rescue breathing

  • Often too fast  compromises circulation
  • Limits chest compressions

Aorta Acidosis Bagging B C C D D E E

Bagging/Breathing

  • AHA CPR guidelines

– De-emphasize importance of bagging/ rescue breathing

  • Often too fast  compromises circulation
  • Limits chest compressions

– Probably not needed in first 5-10 minutes after primary cardiac arrest

  • Initial central O2 saturation is fine!

Aorta Acidosis Bagging B C C D D E E

Bagging/Breathing

  • Pre-hospital and in-hospital care

providers routinely hyperventilate patients during acute resuscitations

– (Even after retraining!)

Aorta Acidosis Bagging B C C D D E E

slide-11
SLIDE 11

Bagging/Breathing

  • Takeaway points

– Avoid hyperventilating pt. during CPR – Avoid hyperventilating pt. in overt shock – Avoid hyperventilation before, during, or after ETI (unless a specific reason to)

  • Be certain patient is not hypovolemic

Aorta Acidosis Bagging B C C D D E E

Bagging/Breathing

  • Takeaway points

– Avoid hyperventilating pt. during CPR – Avoid hyperventilating pt. in overt shock – Avoid hyperventilation before, during, or after ETI (unless a specific reason to)

  • Be certain patient is not hypovolemic

– Be aware of the person performing BVM…tell them to slow down!! – First few minutes of primary CA  no positive pressure ventilations!

Aorta Acidosis Bagging B C C D D E E

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SLIDE 12

Baby on Board??

Aorta Acidosis Bagging Baby?? C C D D E E

Baby on Board??

  • Crashing/arresting female…

– Always consider ruptured ectopic pregnancy – Paradoxical bradycardia common (lack of tachycardia with significant blood loss)

Aorta Acidosis Bagging Baby?? C C D D E E

Baby on Board??

  • Crashing/arresting female…

– Always consider ruptured ectopic pregnancy – Paradoxical bradycardia common (lack of tachycardia with significant blood loss) – Get the U/S!

Aorta Acidosis Bagging Baby?? C C D D E E

Baby on Board??

Aorta Acidosis Bagging Baby?? C C D D E E

  • Case Presentation

– 24 yo woman is 30 weeks pregnant – Presents with ventricular dysrhythmia – Hemodynamically stable – How do you treat her? – What if she were unstable?

slide-13
SLIDE 13

Baby on Board??

  • Dysrhythmias

Aorta Acidosis Bagging Baby?? C C D D E E

Baby on Board??

  • Dysrhythmias

– Amiodarone?

Aorta Acidosis Bagging Baby?? C C D D E E

Baby on Board??

  • Dysrhythmias

– Amiodarone should be avoided in pregnancy

  • The only class D antidysrhythmic
  • Risk of fetal hypothyroidism, IUGR, fetal

bradycardia, prematurity

  • Only rec’d if other drugs fail

– Procainamide, lidocaine preferred for ventricular dysrhythmias

Aorta Acidosis Bagging Baby?? C C D D E E

Baby on Board??

  • Electricity…???

Aorta Acidosis Bagging Baby?? C C D D E E

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SLIDE 14

Baby on Board??

  • Electricity is safe!

– Temporary or permanent pacing safe – AICD safe – Direct current cardioversion safe

  • Fetus has a high fibrillation threshold
  • Amount of current reaching uterus is small
  • Remove fetal and uterine monitors before

shocks!

Aorta Acidosis Bagging Baby?? C C D D E E

Baby on Board??

  • Chest compressions

– International Guidelines recommend compressions higher on sternum

  • Slightly above center of sternum
  • Adjusts for elevation of diaphragm and

abdominal contents

Aorta Acidosis Bagging Baby?? C C D D E E

Baby on Board??

  • Chest compressions

– International Guidelines recommend left lateral tilt position for gravid patients

  • 30% improvement in cardiac output

Aorta Acidosis Bagging Baby?? C C D D E E

Baby on Board??

  • Chest compressions

– Problem: in LLT position only 80% of chest compression force is transmitted

Aorta Acidosis Bagging Baby?? C C D D E E

slide-15
SLIDE 15

Baby on Board??

  • Chest compressions

– Problem: in LLT position only 80% of chest compression force is transmitted – Kiss G, Resuscitation 2004

  • Best compromise for optimal chest

compressions + venous return is supine position with manual displacement of uterus to left

  • i.e. 3-person CPR

Aorta Acidosis Bagging Baby?? C C D D E E

Baby on Board??

  • Chest compressions

– Problem: in LLT position only 80% of chest compression force is transmitted – Kiss G, Resuscitation 2004

  • Best compromise for optimal chest

compressions + venous return is supine position with manual displacement of uterus to left

  • i.e. 3-person CPR

– 2010 AHA Guidelines

Aorta Acidosis Bagging Baby?? C C D D E E

Baby on Board??

  • What if she develops cardiac arrest?

Aorta Acidosis Bagging Baby?? C C D D E E

Baby on Board??

  • “Perimortem C-section”

Aorta Acidosis Bagging Baby?? C C D D E E

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SLIDE 16

Baby on Board??

  • “Perimortem C-section”

Aorta Acidosis Bagging Baby?? C C D D E E

Baby on Board??

  • “Perimortem C-section”

Aorta Acidosis Bagging Baby?? C C D D E E

Baby on Board??

  • “Perimortem fetal extrication”

Aorta Acidosis Bagging Baby?? C C D D E E

Baby on Board??

  • “Perimortem fetal extrication”

– If no maternal ROSC after 4 minutes of compressions and EGA > 20 weeks  perform PFE

Aorta Acidosis Bagging Baby?? C C D D E E

slide-17
SLIDE 17

Baby on Board??

  • “Perimortem fetal extrication”

– If no maternal ROSC after 4 minutes of compressions and EGA > 20 weeks  perform PFE – Maternal cardiac output may improve up to 80% after fetus removed

Aorta Acidosis Bagging Baby?? C C D D E E

Baby on Board??

  • “Perimortem fetal extrication”

– If no maternal ROSC after 4 minutes of compressions and EGA > 20 weeks  perform PFE – Maternal cardiac output may improve up to 80% after fetus removed

  • PFE should be performed even in absence of

fetal viability if no maternal pulse

  • Even if EGA 20-23 weeks!
  • PFE  best chance of maternal survival

Aorta Acidosis Bagging Baby?? C C D D E E

Baby on Board??

  • “Perimortem fetal extrication”

– Medicolegal protection

Aorta Acidosis Bagging Baby?? C C D D E E

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SLIDE 18

Compressions

Aorta Acidosis Bagging Baby?? Compress C D D E E

The AHA Motto… The AHA Motto…

“Push hard… push fast!”

The AHA Motto…

“Push it good… push it real good!”

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SLIDE 19

The AHA Motto…

“Push it good… push it real good!”

The AHA Motto…

“Push hard… push fast…and don’t stop!”

Compressions

  • Takeaway points of recent literature

regarding CPR

– We should be optimizing the basics

  • Proper compression rates
  • Minimizing interruptions of compression

Aorta Acidosis Bagging Baby?? Compress C D D E E

Compressions

  • Takeaway points of recent literature

regarding CPR

– We should be optimizing the basics

  • Proper compression rates
  • Minimizing interruptions of compression

– Use ETCO2 to indicate ROSC (2010)

Aorta Acidosis Bagging Baby?? Compress C D D E E

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SLIDE 20

Compressions

  • Takeaway points of recent literature

regarding CPR

– We should be optimizing the basics

  • Proper compression rates
  • Minimizing interruptions of compression

– Use ETCO2 to indicate ROSC (2010) – Interrruptions for defib (coming up…)

Aorta Acidosis Bagging Baby?? Compress C D D E E

Compressions

  • Takeaway points of recent literature

regarding CPR

– We should be optimizing the basics

  • Proper compression rates
  • Minimizing interruptions of compression

– Use ETCO2 to indicate ROSC (2010) – Interrruptions for defib (coming up…)

  • 2-person CPR  30:2 ratio
  • Proper bagging rates (8-10/minute max.)
  • Rapid defibrillation (more later…)

Aorta Acidosis Bagging Baby?? Compress C D D E E

Compressions

  • Case presentation

– A 65 yo man had a witnessed cardiac arrest – Pulses were regained in the field – Arrives unconscious with a pulse – What do you do next?

Aorta Acidosis Bagging Baby?? Compress C D D E E

Cooling

  • Therapeutic hypothermia

– Unconscious adults with spontaneous

  • ut-of-hospital cardiac arrest (initial VF)

Aorta Acidosis Bagging Baby?? Compress Cooling D D E E

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SLIDE 21

Ice Ice Baby!

  • Therapeutic hypothermia

– Unconscious adults with spontaneous

  • ut-of-hospital cardiac arrest (initial VF)

Aorta Acidosis Bagging Baby?? Compress Cooling D D E E

Ice Ice Baby!

  • International Guidelines

– Unconscious adults with spontaneous

  • ut-of-hospital cardiac arrest and initial

rhythm of VF that have ROSC

  • Cool to 32-34 degrees celsius (~90-93 F) for

12-24 hours

– Presumed beneficial for other rhythms or for in-hospital cardiac arrest – But…

Aorta Acidosis Bagging Baby?? Compress Cooling D D E E

Ice Ice Baby!

Aorta Acidosis Bagging Baby?? Compress Cooling D D E E

Ice Ice Baby!

Targeted Temperature Management at 33oC vs. 36oC After Cardiac Arrest (Nielsen, et al. NEJM 2013)

Aorta Acidosis Bagging Baby?? Compress Cooling D D E E

slide-22
SLIDE 22

TrenDelenburg

Myth: The Trendelenburg Position

Aorta Acidosis Bagging Baby?? Compress Cooling Decline D E E

slide-23
SLIDE 23

TrenDelenburg

Myth: The Trendelenburg Position Improves Circulation in Cases of Shock (Johnson, Can J Emerg Med 2004)

  • Reviewed studies (4) which evaluated

efficacy of T-Burg position for patients in shock

  • Conclusion…

Aorta Acidosis Bagging Baby?? Compress Cooling Decline D E E

TrenDelenburg

Myth: The Trendelenburg Position Improves Circulation in Cases of Shock (Johnson, Can J Emerg Med 2004)

  • Reviewed studies (4) which evaluated

efficacy of T-Burg position for patients in shock

  • Conclusion…it doesn’t work!

Aorta Acidosis Bagging Baby?? Compress Cooling Decline D E E

TrenDelenburg

  • Studies indicate that Trendelenburg

– Fails to increase BP, CO, and oxygenation in most – Decreases CO in hypotensive patients – Results in displacement of only 1.8% of total blood volume – Increases RV stress – Worsens pulmonary function

Aorta Acidosis Bagging Baby?? Compress Cooling Decline D E E

TrenDelenburg

  • Especially harmful in morbidly obese

and in late pregnancy

Aorta Acidosis Bagging Baby?? Compress Cooling Decline D E E

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SLIDE 24

Defibrillation

  • New concepts in defibrillation focused
  • n minimizing hands-off time to

maximize compressions

Aorta Acidosis Bagging Baby?? Compress Cooling Decline Defib E E

Defibrillation

Edelson, Resuscitation 2010

  • Typically there are 10-15 seconds of

hands-off time for charging the defib.

  • 10 seconds of hands-off time prior to
  • defib. decreases chance of ROSC by

~ 50% due to reduced CPP

  • After 5 seconds of hands-off time, it

takes ~7 compressions to return CPP back to pre-interruption level

Aorta Acidosis Bagging Baby?? Compress Cooling Decline Defib E E

Defibrillation

Edelson, Resuscitation 2010

  • Recommended charging during the

compressions

  • Reduced hands-off time during defib.

from 14.8 to 3.9 seconds

  • (already recommended by AHA)

Aorta Acidosis Bagging Baby?? Compress Cooling Decline Defib E E

Courtesy Dr. Abdulrahman

slide-25
SLIDE 25

Case Presentation

  • 56 yo woman with history of breast

cancer presents with CP + SOB

– Afebrile, tachypnea, tachycardia – Stable BP – Pulse ox 96% – Clear lungs, JVD – ECG  no evidence of acute MI

  • What’s the diagnosis and treatment?

Aorta Acidosis Bagging Baby?? Compress Cooling Decline Defib E E

Pericardial Effusion vs. Pulmonary Embolus

Aorta Acidosis Bagging Baby?? Compress Cooling Decline Defib Effusion Embolus

slide-26
SLIDE 26

Pericardial Effusion vs. Pulmonary Embolus

Aorta Acidosis Bagging Baby?? Compress Cooling Decline Defib Effusion Embolus

  • Similar presentations

– Often history of cancer, other similar RFs – Dyspnea, tachycardia, tachypnea, sick! – Severe cases: JVD + hypotension + clear lungs – Cardiac arrest  often PEA initially

  • Treatment is enormously different!

– Pericardiocentesis vs. A.C./lytics

Pericardial Effusion vs. Pulmonary Embolus

Aorta Acidosis Bagging Baby?? Compress Cooling Decline Defib Effusion Embolus

E

Pericardial Effusion vs. Pulmonary Embolus

Aorta Acidosis Bagging Baby?? Compress Cooling Decline Defib Effusion Embolus

ECHO

Pericardial Effusion vs. Pulmonary Embolus

Aorta Acidosis Bagging Baby?? Compress Cooling Decline Defib Effusion Embolus

  • Bedside ECHO very useful
slide-27
SLIDE 27

Pericardial Effusion vs. Pulmonary Embolus

Aorta Acidosis Bagging Baby?? Compress Cooling Decline Defib Effusion Embolus

  • Bedside ECHO very useful: effusion

Systole

Pericardial Effusion vs. Pulmonary Embolus

Aorta Acidosis Bagging Baby?? Compress Cooling Decline Defib Effusion Embolus

  • Bedside ECHO very useful: embolus

Diastole

Large Pericardial Effusions

Aorta Acidosis Bagging Baby?? Compress Cooling Decline Defib Effusion Embolus

Pearls and pitfalls

  • Dyspnea caused by pericardial fluid

compressing bronchial structures

– Pulse ox. usually normal despite dyspnea and tachypnea – Patients may also have dysphagia, hoarseness due to fluid compression

Large Pericardial Effusions

Aorta Acidosis Bagging Baby?? Compress Cooling Decline Defib Effusion Embolus

Pearls and pitfalls

  • Dyspnea caused by pericardial fluid

compressing bronchial structures

  • Marked cardiomegaly
slide-28
SLIDE 28

Large Pericardial Effusions

Aorta Acidosis Bagging Baby?? Compress Cooling Decline Defib Effusion Embolus

Pearls and pitfalls

  • ECG triad: Electrical alternans (less

than 30%), low voltage, tachycardia

Large Pericardial Effusions

Aorta Acidosis Bagging Baby?? Compress Cooling Decline Defib Effusion Embolus

Pearls and pitfalls

  • ECG triad: Electrical alternans (less

than 30%), low voltage, tachycardia

Large Pericardial Effusions

Aorta Acidosis Bagging Baby?? Compress Cooling Decline Defib Effusion Embolus

Pearls and pitfalls

  • ECG triad: Electrical alternans (less

than 30%), low voltage, tachycardia

Large Pericardial Effusions

Aorta Acidosis Bagging Baby?? Compress Cooling Decline Defib Effusion Embolus

Pearls and pitfalls

  • ECG triad: Electrical alternans (less

than 30%), low voltage, tachycardia

slide-29
SLIDE 29

Large Pericardial Effusions

Aorta Acidosis Bagging Baby?? Compress Cooling Decline Defib Effusion Embolus

Pearls and pitfalls

  • ECG triad: Electrical alternans (less

than 30%), low voltage, tachycardia

Large Pericardial Effusions

Aorta Acidosis Bagging Baby?? Compress Cooling Decline Defib Effusion Embolus

Large Pericardial Effusions

Aorta Acidosis Bagging Baby?? Compress Cooling Decline Defib Effusion Embolus

Pearls and pitfalls

  • Patients are very preload dependent

– IVF usually help BP

Large Pericardial Effusions

Aorta Acidosis Bagging Baby?? Compress Cooling Decline Defib Effusion Embolus

Pearls and pitfalls

  • Patients are very preload dependent

– IVF usually help BP – Beware intubation!!

slide-30
SLIDE 30

Large Pericardial Effusions

Aorta Acidosis Bagging Baby?? Compress Cooling Decline Defib Effusion Embolus

Pearls and pitfalls

  • Patients are very preload dependent

– IVF usually help BP – Beware intubation!!

  • PPV  preload and CO fall  cardiac arrest
  • Most patients are NOT hypoxic anyway!

Massive Pulmonary Embolus

Aorta Acidosis Bagging Baby?? Compress Cooling Decline Defib Effusion Embolus

Pearls and pitfalls

  • Patients are very preload sensitive

– IVF often don’t help, may hurt!

Massive Pulmonary Embolus

Aorta Acidosis Bagging Baby?? Compress Cooling Decline Defib Effusion Embolus

Pearls and pitfalls

  • Patients are very preload sensitive

– IVF often don’t help, may hurt!

Systole Diastole

Massive Pulmonary Embolus

Aorta Acidosis Bagging Baby?? Compress Cooling Decline Defib Effusion Embolus

Pearls and pitfalls

  • Patients are very preload sensitive

– IVF often don’t help, may hurt!

  • RV overload causes septum to bulge into LV
  •  Decreased LV filling
  •  Decreased SV, CO, BP
  • IVF may worsen this process
  • Use vasopressors instead
slide-31
SLIDE 31

Massive Pulmonary Embolus

Aorta Acidosis Bagging Baby?? Compress Cooling Decline Defib Effusion Embolus

Pearls and pitfalls

  • Patients are often hypoxic
  • Intubation shouldn’t hurt

– May even help the BP by decreasing venous return

Massive Pulmonary Embolus

Aorta Acidosis Bagging Baby?? Compress Cooling Decline Defib Effusion Embolus

Pearls and pitfalls

  • ECG: Rightward axis, new T-wave

inversions (esp. V1-V3, inferior leads)

Massive Pulmonary Embolus

Aorta Acidosis Bagging Baby?? Compress Cooling Decline Defib Effusion Embolus

Pearls and pitfalls

  • ECG: Rightward axis, new T-wave

inversions (esp. V1-V3, inferior leads)

Massive Pulmonary Embolus

Aorta Acidosis Bagging Baby?? Compress Cooling Decline Defib Effusion Embolus

Pearls and pitfalls

  • ECG: Rightward axis, new T-wave

inversions (esp. V1-V3, inferior leads)

slide-32
SLIDE 32

Massive Pulmonary Embolus

Aorta Acidosis Bagging Baby?? Compress Cooling Decline Defib Effusion Embolus

Pearls and pitfalls

  • Hemodynamically unstable/cardiac

arrest with pulmonary embolus  indication for lytics

Massive Pulmonary Embolus

Aorta Acidosis Bagging Baby?? Compress Cooling Decline Defib Effusion Embolus

Pearls and pitfalls

  • Hemodynamically unstable/cardiac

arrest with pulmonary embolus  indication for lytics

  • Evidence of RV dilation  lytics

Systole Diastole

Summary-A

Aorta Acidosis Bagging Baby?? Compress Cooling Decline Defib Effusion Embolus

  • Consider TAD and AAA in all crashing
  • r arresting patients regardless of

prior symptoms.

  • Beware intubation of the patient with

severe metabolic acidosis…mind the ventilatory rate!

slide-33
SLIDE 33

Summary-B

Aorta Acidosis Bagging Baby?? Compress Cooling Decline Defib Effusion Embolus

  • Avoid hyperventilating patients

during the peri-ETI period and in cardiac arrest (unless severe M.A.).

  • Baby on board??

– Consider ruptured ectopic pregnancy – Avoid amiodarone – Chest compressions supine with gravid uterus manually displaced – Perimortem fetal extrication: 4th minute

Summary-C

Aorta Acidosis Bagging Baby?? Compress Cooling Decline Defib Effusion Embolus

  • Do everything possible to optimize

compressions

– Minimize interruptions – Compression rate should be 100/min

  • Cool unconscious victims of VF arrest

Summary-D

Aorta Acidosis Bagging Baby?? Compress Cooling Decline Defib Effusion Embolus

  • Trendelenburg doesn’t work!
  • Defibrillation

– Do everything possible to minimize hands-off time when defibrillating

Summary-E

Aorta Acidosis Bagging Baby?? Compress Cooling Decline Defib Effusion Embolus

  • Pericardial effusion: CMG, normal sats.,

low voltage + tachycardia, IVF.

  • Massive PE: hypoxia, new T-wave

inversions, beware IVF, consider lytics.

slide-34
SLIDE 34

Summary

Aorta Acidosis Bagging Baby?? Compress Cooling Decline Defib Effusion Embolus

Thanks!

amalmattu@comcast.net