Resuscitation

Non shockable :

• pulseless electrical activity

• asystole

Shockable :

• pulseless ventricle tachycardia

• VFib (can’t have pulse)

Pulse VT - cardioversion → 70-120J, sedate patient, up to 3 shocks, shocks must be synchronous w/ r wave

Supraventricular tachycardia → try Valsava first (blow into syringe), adenosine

CPR:

Check for breathing - for 10s (look, listen, feel)

• 30 compressions

  - depth 1/3 of thorax

  - let thorax refill

  - lift fingers of other hand so pressure is on palms

  - lower half of sternum

• 2 ventilations - head lift, chin lift IF NO TRAUMA

  - 2 fingers on chin, 1 palm on forehead

  - if cervical spine lesion -> jaw thrust, 3 fingers behind mandible, palms on face, thumbs on mandible, lift it forwards and push chin down

  

• <2s to stop compressions when checking rhythm during defib

• Pacemaker - 8cm from device (@ scapula)

• Pulse - use central pulse (femoral, carotid)

Resus Protocol

If shockable : 1mg ADRENALINE + 300 → 150mg AMIODARONE every 4m, after 3rd + 5th shocks, bag mask then intubate

If non-shockable : 1mg ADRENALINE (to bring back to shockable rhythm), then every 4m (even if it becomes shockable), immediate intubation

• 20-30m → stop maneuvers

• If shockable → continue Resus

* after switching to advanced ventilation - 10 breaths/m

If pulse back → check breathing

• If <6 breaths/min continue ventilating, until 12breaths/min

• Check abnormal lung sounds

How to check if ventilation works - check co2

• sudden increases ETCO2 (>45mmHg) after initiation CPR → sign of ROSC

If cant get IV access - IO (tibia or humeral head)

Airway Desobstruction:

Partial : encourage cough

Severe (silent) : 5 back blows, 5 abd thrusts - repeat until unconscious -> cardiac arrest → Resus

* McGill forceps for solid removal

• stridor - inspiratory, by obstruction at laryngeal level or above

• wheeze - expiratory, by obstruction of lower airways

• gurgling - by l or semisolid foreign material

• snoring - pharynx occluded by soft palate or epiglottis

• crowing - sound of laryngeal spasm

In conscious patients - nasopharyngeal Wendel → hold like pen, into nostrils

• CO in trauma

In unconscious patients - oropharyngeal Guedel pipe

• measure it

• insert other way then rotate

• 

Venturi mask (w/ colourful valves) - constant o2

Mask w/ bag

• CO - copd

Ampi bag (yellow band around neck)

Wendel pipe (nasopharyngeal) - palliative

Laryngeal mask (brown), i-Gel (green) - preferred to bag-mask

Combitube (tube 1 blue, tube 2 smaller)

• Make letter C w/ fingers to push mask on face, letter e lifts chin

Pregnant woman: Patient in left lat decubitus (15-20d) to remove p from IVC

• belly @ umbilicus - 20w

• fundus of uterus bw umbilicus + sternum - 25w

• fundus to diaphragm, belly occupying abd - 30-34w

Intubate asap (big risk aspiration reflux)

Same drugs + shocks

If after 5 min of advanced resuscitation -> peri-mortem c-section if after 20w (call neonatologist and obgyn)

Drowning: 5 rescue breaths asap

Same maneuver for cardiac arrest (dry chest first)

Intubate asap (high risk aspiration)

Immobilize c spine with c-collar if suspect trauma

Hypothermia:

32-35 - rewarm, rewarmed saline in 2+ big IVs (urinary catheter, nasogastric tube, infuse normal saline). blankets

28-32 - mild, warming, cardiac arrest (?)

<28 - severe, chest drains, wash pleural space with saline, peritoneal wash

Gold standard - ECMO (hemodialysis for hypothermia)

Move patient carefully (can cause arrhythmias), remove clothing

Try 3 shocks without break bw, and if it doesn't work then don't shock until 30° → Double dose and double time - 2mg adrenaline 6 @ 10m

Can't give drugs or shocks under 30°

Osborne sign on ecg - sinus bradycardia

No resus if patient under snow for hrs

Electrocution: Lesion like burn (on hand), lesions of heart, m, n, bones

Risk arrhythmias

Cardiac arrest - monitor -> defib, intubate (drugs + dose the same)

C-spine collar

Protocol - liquids (crystalloids), atb

Toxins: no mouth-mouth, don’t go in facility, certain ppl take patients out

• Alcohol - metabolic acidosis, hepatic + renal failure -> ER dialysis

• CO - give O2 high flow, get ABG (carboxyhb), dizziness, vomit, red face, coma, seizure, arrythmias

• Pills - if <1.5h do gastric lavage

- gastric lavage within an hour, activated charcoal 1g/kilo

- nasogastric tube if altered mental status, charcoal nasogastric

Antidotes:

Paracetamol - acetyl cysteine

Opioids - nalaxone

Benzos - flumazenil

Organophosphates (farmers w/ salivation, lacrimation, big urinary output, wet, diarrhea) -> atropine, repeated until dry

Ca+ channel blockers - give Ca+

Tricyclic antidepressants - sodium bicarb

Dialysis for substances

Burns: Immediate intubation, Parkland fluid amount (first 5h give half, 18h second half)

Check int bleed trauma (signs - shock, pain, tenderness, swelling around area)

Moist covers + gels

Infection:

Check procalcitonin (sepsis), lactate >4mmol (sign of hypoxia and low perfusion)

• Stable - antipyretics if temp

• Unstable - 30ml crystalloids/kg bolus

• Atb - ceftriaxone in first hr

• Sepsis - fluids, vasopressors, NOR, atb, 2 hemocultures (within golden hour)

Anaphylactic shock:

Remove agent, ABCDE protocol, IV lines big caliber, meds (IM adrenaline every 10-15m until response→ hydrocortisone), cricotracheostomy if can’t intubate

Cardiogenic shock:

• Due to MI, valve or m. rupture - heart can't pump

• Treat infarction → PTCA (percutaneous transluminal coronary angioplasty), antiplatelets (aspirin, clopidogrel), O2 (<85), morphine until no pain, nitrates (not in inferior wall MI)

• Treat dysfxn heart contractility→ inotropes (dobutamine), NOR

Neurogenic shock:

• Hypotension, bradycardia due to spine injury

• Treatment - surgery, inotropes, vasopressors

Obstructive shock: tension pneumothorax, tamponade, PE (→ give thrombolytics then prolonged cpr 90m)

• Treat cause

  
  

Trauma:

First 5 s : check for

1. major bleed - press with hands, use tourniquet when it doesn’t work (5-7cm above bleeding point)

2. airway obstruction - take out, suction (Yankauer), Guedel pipe if under GCS 8, jaw thrust, O2

3. check if alive -> CPR

First evaluation: find all traumatic lesions that can kill patient in 30-40m

(ABCDE approach also done if ROSC)

Airway - look, hear (stridor in upper obstruction -> remove obstruction, snoring if tongue relaxed -> jaw thrust, wheezing in lower obstruction, gurgling if fluids -> suction, apply gurgle tube), cervical collar

Breathing - look, listen (10s), percussion, hands on thorax (rib fractures), auscultate, subcutaneous emphysema

- tension pneumothorax -> no sounds or movements on one side, jugular v distention, trachea deviated, bp decreasing, not responding to restoration v. or airway opening, hypersonority on other side, subcutaneous emphysema -> puncture 2nd intercostal on midclavicular line above lower rib THEN resuscitative thoracotomy midaxillary line 4th or 5th intercostal space, on upper margin of lower rib, atb

- massive hemothorax -> check w/ US (also eFAST), self saver kit, give blood from the hemothorax (massive transfusion protocol)

• >1500ml drained - thoracotomy

*eFAST : pericardial tamponade + pneumothorax

* Chest tube insertion - bubbling is sign of air draining from pleura, persistent bubbling → broncho-pleural fistula

- open pneumothorax (penetrating wounds) -> seal it, 3 sided occlusive dressing, Asherman chest seal, intercostal catheter insertion

- flail chest - 3+ ribs broken bilaterally -> paradoxical chest movements, hypoxia, hypercapnia (>45mmHg) -> put tape around flailing parts

- tamponade -> US, muffled heart sounds, distended jugular veins -> syringe from epigastrium to left shoulder, aspirate epicardium

• do pericardiocentesis if patient in peri-arrest or cardiac arrest w/ tamponade - 18-22g needle inserted to subxiphoid space, directed to left shoulder, once aspirated cannula is advanced to pericardial space

• Beck’s triad - hypotension, increased JVP, muffled heart sounds

- airway rupture -> check w/ US, bilateral pneumothorax sign, drain

- major tracheo-bronchial injuries - careful intubation, 2 intercostal catheters to allow lung to fully inflate

- trachea midline? - deviated in tension pneumothorax

* Jugular vein distention = tamponade and tension pneumothorax

* don't remove c spine until final evaluation done (CT scan, imaging, conscious and says no pain)

Circulation - Bp, heart frequency, look for bleeding (by FAST), capillary refill on sternum (>3s), ECG, blood test

- give transfusion + tranexamic acid 1g in 10m then continuous on automatic syringe, O2, permissive hypotension, limited fluids/saline but 1:1:1 frozen plasma, thrombocytes, rbc, vasoconstrictors, BP no more than 80/90, x2 large bore IV access

IF hypovolemia (as source of cardiac arrest): initial fluid bolus 20ml/kg of crystalloid fluid

- massive hemothorax - needs the same, chest tube

- amputation -> traction splint

- pelvic - traction splint, pelvic binder, tranexamic acid, blood products, hypotension

Disability - pupils (reactive, intermediate size, bilateral), maintain sedation

- Glasgow under 8 → intubation

- verbal tactile and pain stimulus -> open eyes, how are movements

- if rxn only to pain -> GCS <8 (coma)

- glycemia

- cap refill (hold 5 sec, >3s too long)

Environment - temperature, toxins, modifications of skin, devices or foreign bodies, look for sites of possible hemorrhages

* HYPOTENSION : blood loss + tension pneumothorax

Secondary evaluation: see, touch, hear ; take history

1. Head - look, feel, palpate (for bone integrity, not if patient says they have face pain), pupils + eyes, small bleedings

2. Chest - look, palpate, percuss, auscultate

- modifications - integrity, crepitus, movements symmetrical/not

3. Upper limbs - keep alignment, splint, look at ability and colour

4. Abdomen - bruises, open wounds, liver or spleen rupture

5. Pelvic ring -> press front to back at iliac crest, lateral movements -> pelvic binder @ big trochanters level, controls abd bleeding, DRE

- bladder -> blood at urethral meatus, rupture urethra (CO for catheter), hematoma, high riding prostate -> post. urethral rupture

6. Lower limbs - look for sensation in feet, palpate pulse (femoral, popliteal, dorsal pedis), colour , bony palpation

- fracture → hemorrhagic shock, patient cry from severe pain, leg abnormally rotated, leg shortened -> immobilize

7. Roll-over - 3+ ppl, 1 person for head + commands, 2 others roll (1 on shoulder opposite to side, other hand on pelvic ring, other 1 on extremities and crossing over to pelvic ring)

- check back of skull (after temporarily removing collar) sensitivity of spine, palpation of spine, observing

C- collar - tell patient

- with right hand, measure with fingers on neck

Signs of head trauma - otorrhagia, retroorbital bruise, Battle’s sign (ecchymosis over mastoid)

Mobilizing

Scoop stretcher

- separate stretcher in 2 pieces, roll under back

- if patient on belly or lat -> mobilize head, put arm over head, stretch feet, place stretcher laterally, roll patient onto it

Vacuum splints - for fxs

- suction air out to mold onto limb

Closed fx - reduce before splint (grab proximal and distal joints and pull), give pain meds, check colour + pulse below splint, look for paleness, cyanosis, numbness

- never put bone back in

- give atb asap

4Hs 4Ts

Hypoxemia (hypoxia), hypovolemia, hyper/hypokalemia, hypothermia

Tamponade, tension pneumothorax, thrombosis, toxins

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