Transcript Block 17: Cardiopulmonary resuscitation, shock

Block 17: Cardiopulmonary
resuscitation, shock
management, transportation
and alcohol in trauma
A Engelbrecht
2013
Three measures makes a big
difference:
 High quality CPR
 Early defibrillation
 Treating reversible causes
Cardiopulmonary resuscitation
 Most victims of out of hospital sudden cardiac
arrest do not receive any bystander CPR
 Why do you think this is the case?
 What can be done to improve on this?
 Continued emphasis on high quality CPR
 Compression rate of at least 100/min (a
change from “approximately” 100/min
 Compression depth of at least 2 inches (5cm)
in adults and children and 1.5inches (4cm) in
infants
Change from A-B-C to C-A-B
 Who is excluded from this sequence?
 The vast majority of adult cardiac arrest
cases are?
 Who has the highest survival rate from
cardiac arrest?
 What are the critical elements of resuscitation
in these cases?
 CPR are delayed by responders retrieving
barrier devices and assembling ventilation
equipment
Chain of survival
 Should you call for help first or first do one
cycle of chest compressions?
Chain of survival includes:
 Recognition of cardiac arrest
 Activation of the EMS
 Early CPR
 Rapid Defibrillation
 Effective advanced life support
 Integrated post cardiac arrest care
What to do if a bystander is not trained
in CPR?
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Hands only CPR
Compressions only CPR
“Push hard and Fast”
Continue until AED arrives or EMS arrives
and take over care of the victim
 If trained to provide rescue breaths – 30
compressions to 2 breaths
 Survival rates from cardiac arrest of cardiac
aetiology are similar for hands only and
compressions plus rescue breaths
Major chances in advanced
cardiovascular life support
 Quantitative wave form capnography is
recommended for monitoring of endotracheal
tube placement and CPR quality
 Atropine is no longer recommended for
routine use in the management of PEA
End tidal CO2 and termination of resus
 End tidal CO2 monitoring confirm the futility of
resuscitation and forecast likelihood of resuscitation
 End-tidal carbon dioxide level of 10 mmHg or less
measured 20 minutes after the initiation of advanced
cardiac life support accurately predicts death in
patients with cardiac arrest associated with electrical
activity but no pulse
 Cardiopulmonary resuscitation may reasonably be
terminated in such patients –
 Ref: Levine R, End-tidal Carbon Dioxide and
Outcome of Out-of-Hospital Cardiac Arrest, New
England Journal of Medicine.
Medications in ALS
 Atropine is no longer reccomended for routine
use in PEA or asystole and has been
removed from the ACLS cardiac arrest
algorithm
 When would atropine be appropriate for use
in cardiac arrest?
Organised post cardiac arrest care:
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New section in the 2010 AHA guidelines
Comprehensive structures system
Cardiopulmonary and neurological support
Theraputic hypothermia
PCI
Tapering inspired oxygen concentration after ROSC
based on saturation
 Maintain saturation > 94%
 Avoid hyperoxia
 At SO2 of 100% the PO2 can vary between 80 and
500
Important causes for cardiac arrest in
Trauma
 Hypoxia – airway obstruction - ↓ LOC;
breathing problems – tension pneumothorax
flail chest etc.
 Hypoperfusion – cardiac tamponade /
hypovolaemia
 Primary rhythm is usually PEA or asystole. VF
not as common
Management
 Focus pre-hospital resuscitation to safely
extricate and attempt to stabilize patient and
minimize interventions that delay transport to
definitive care \
 On scene: blunt trauma and cardiac arrest.
Poor prognosis. Stop CPR if no response in 5
minutes
 Penetrating trauma – better prognosis
 Primary survey C-A-B-C management
Emergency Department
Thoracotomies:
 2002 report: resuscitative thoracotomies for trauma patients in
the ED, the 3 survivors of 10 victims of penetrating trauma all
had signs of life and vital signs on arrival at the ED. In contrast,
all 19 patients with blunt trauma died, despite the fact that 14 of
the 19 “had vital signs” at the time of the thoracotomy
 In a database of 959 resuscitative thoracotomies, 22 victims of
penetrating trauma and 4 victims of blunt trauma survived to
hospital discharge after receiving prehospital CPR (overall
survival rate of 3%).
 In 2001 the Committee on Trauma of the American College of
Surgeons published a systematic review of 42 studies of ED
thoracotomies involving nearly 7000 patients, published from
1966 to 1999. In this database, survival was 11% (500 of 4482)
for victims of penetrating trauma and 1.6% (35 of 2193) for
victims of blunt trauma.
Suggested Indications for Resuscitative Thoracotomy:
Patients With Traumatic Cardiac Arrest
Type of Injury
Assessment
Penetrating cardiac
trauma
Patient experiences a witnessed cardiac arrest in ED or trauma center
or • Patient arrives in ED or trauma center after <5 minutes of out-ofhospital CPR and with positive secondary signs of life (eg, pupillary
reflexes, spontaneous movement, organized ECG activity)
Blunt trauma
Patient arrives at ED or trauma center with pulse, blood pressure, and
spontaneous respirations, and • then experiences witnessed cardiac
arrest
Penetrating thoracic
(noncardiac) trauma
Patient experiences a witnessed cardiac arrest in ED or trauma center
or • Patient arrives in ED or trauma center after <15 minutes of out-ofhospital CPR and with positive secondary signs of life (eg, pupillary
reflexes, spontaneous movement, organized ECG activity)
Exsanguinating
abdominal vascular
trauma
Patient experiences a witnessed cardiac arrest in ED or trauma center
or • Patient arrives in ED or trauma center with positive secondary signs
of life (eg, pupillary reflexes, spontaneous movement, organized ECG
activity) plus • Resources available for definitive repair of abdominalvascular injuries
Damage control resuscitation
 Permissive hypotension
 Haemostatic resuscitation
 Damage control surgery
Transportation of the trauma patient
 Reasons for transporting a patient – Inter- or
intrahospital transport.
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Need for more advanced diagnostic
procedures e.g. CT, MRI
Need for more advanced therapeutic
procedures e.g. surgery
Transfers to a tertiary facility
Potential complications/risks
associated with transportation
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Equipment failure/ malfunction
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Respiratory system
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Hypotension
Hemorrhage
Arrhythmias
Loss of vascular access
Neurological deterioration
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Hypo- or hyperventilation
Acute desaturation & drop in PaO2
Acid base disturbances
Airway loss/problem
Cardiovascular system
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Dislodgment of tubes such as thoracostomy tube, Foley catheter, surgical drain
Disconnection from ECG or ventilator
Power failure
Failure of suction apparatus
Increase in intracranial pressure
Decrease in cerebral perfusion
Hypoxia
Other:
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Death e.g. acute pulmonary embolus
Collision risk
Temperature changes
Planning/preparation
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Earlier transport rather than later as soon as the decision is made to
transport the patient.
The patient must be stable for transportation: resuscitation before
transport (with crystalloids or blood products as indicated).
Correct possible electrolyte disturbances & precipitants.
Inspect all invasive catheters and establish vascular access as
necessary. Remove air from all intravenous catheters and bags.
Inspect the airway for position and stability. Restabilize or reposition as
necessary.
Review radiographs and laboratory data.
When necessary, perform procedures such as bronchoscopy, central
catheter insertion, or thoracostomy tube insertion before departure.2
Minimize continuous medication infusions to necessary vasoactives
and volume expanders.2
Discontinue infusions of paralytics and/or sedatives; those agents are
given by bolus during transport.2
Do not move the patient until the blood gases are considered
satisfactory and hemodynamic stability has been achieved or
optimized.
Communication:
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Direct communication between teams on both
sides: physician-to-physician and nurse-tonurse.2
Make sure the area where the patient is meant
to be moved is ready to receive him/her.1
Adequate documentation – incl. transport
permission forms and test results must
accompany the patient.
Driver/ pilot must be aware of all the hospitals
located between the sending and receiving
hospitals.2
Personnel
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One of the professionals should be the nurse in
charge of the patient, with experience in CPR or
specially trained in transport of patients in
serious conditions.
In accordance with the serious condition and
instability of the patient, the second professional
can be a doctor, nurse or paramedic.
A doctor should accompany the patient who
presents with physiological instability and who
might need an urgent action.
Modes of transport
 Choice depends on transport distance, medical
condition of the patient, staff and resources
availability, weather forecast and necessary medical
procedures during transport.1
 In case of air transport it is also important to be
aware of possible physiological changes regarding
the altitude and its influence on clinical features.
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0 - 200 km: road ambulance or helicopter if urgent.
200 - 300 km: road ambulance, helicopter or fixed-wing
air ambulance depending on condition.
> 300 km: fixed-wing air ambulance.
Scheduled (commercial) service for stable patients
only.
Alcohol in trauma
 Role of alcohol
 Alcohol Hampers Diagnosis
 Other complications: electrolyte and fluid
imbalance, blood coagulation problems,
cardiomyopathy, hepatic dysfunction, and
alcohol withdrawal
 Bias against treating an inebriated patient
who is uncooperative and disruptive may lead
to quick disposition of that case in order to
free up time for more "deserving" patients