新光急診新光急診 張志華張志華

病人爆掉了怎麼辦病人爆掉了怎麼辦病人爆掉了怎麼辦病人爆掉了怎麼辦？？？？病人爆掉了怎麼辦病人爆掉了怎麼辦病人爆掉了怎麼辦病人爆掉了怎麼辦？？？？

Case 1: 55Y MCase 1: 55Y M

�� CC: CC:

�� 腳踝扭傷，照完片子後，全身不舒服腳踝扭傷，照完片子後，全身不舒服

�� 躺也不是坐也不是，不喘躺也不是坐也不是，不喘

�� Denied chest/back/belly painDenied chest/back/belly pain

�� PH: HTN, DMPH: HTN, DM

�� PE:PE:

�� Awake, diaphoretic, look sickAwake, diaphoretic, look sick

�� AfebrileAfebrile, PR 120, RR 28, BP 85/40, , PR 120, RR 28, BP 85/40,

�� SpO2 96%, F/S 120SpO2 96%, F/S 120

What's next?What's next?

�� MxMx::

�� O2 maskO2 mask

�� on 2 largeon 2 large--bore IVbore IV

�� on monitorson monitors

�� What's next?What's next?

�� ECG: Sinus tachycardiaECG: Sinus tachycardia

�� ABGsABGs: Metabolic acidosis: Metabolic acidosis

What's next?What's next?

�� The 4 triadsThe 4 triads

�� AA--BB--CC

�� O2O2--IVIV--MonitorMonitor

�� Vital signs: BPVital signs: BP--PRPR--RRRR

�� DDxDDx: : HxHx--PEPE--LabLab

What's next?What's next?

�� Give me data... Give me data... 陷阱！陷阱！

�� CBC+DC, BCS/MAR, CXR, BNP, DCBC+DC, BCS/MAR, CXR, BNP, D--dimerdimer, ,

U/A, ....U/A, ....

�� About 1 hour delayAbout 1 hour delay

�� What shouldWhat should you doyou do in the mean time?in the mean time?

Crashed!Crashed!

�� During portable CXR During portable CXR ……�� Conscious lossConscious loss

�� PEAPEA

AortaAorta

� Aortic dissection/rupture

� Immediate cause of cardiac arrest in 2.3%

� Common features :

� previously known aortic aneurysm,

� old age,

� male,

� PEA

MeronMeron G et al: NonG et al: Non--traumatic aortic dissection or rupture as cause of cardiac arrestraumatic aortic dissection or rupture as cause of cardiac arrest: presentation and t: presentation and

outcome. outcome. ResuscitationResuscitation. 2004 Feb;60(2):143. 2004 Feb;60(2):143--50.50.

AortaAorta

�� Atypical presentation in half of the timeAtypical presentation in half of the time�� AAAAAA: 48% have no abdominal pain : 48% have no abdominal pain hxhx

�� ThoracicThoracic ADAD: 52% : 52% hvehve no chest pain no chest pain hxhx

�� Cardiac arrest with initial PEACardiac arrest with initial PEA�� Always think of PE, but Always think of PE, but thrombolyticsthrombolytics controversial controversial (should rule out AAA or AD)(should rule out AAA or AD)

�� Bedside Bedside echoecho�� Almost always diagnosticAlmost always diagnostic

�� Crashing Crashing p'tp't = always echo = always echo -- heart and abdomen !!heart and abdomen !!

Case ProgressionCase Progression

�� MxMx::

�� ABC: ETT, ACLS...ABC: ETT, ACLS...

�� EUS: large pericardial effusion with EUS: large pericardial effusion with tamponadetamponade

�� PericardiocentesisPericardiocentesis ... using CVP kit... using CVP kit

�� Regained GCS and vital signs Regained GCS and vital signs -- tansfertansfer for OP and for OP and

survivedsurvived

IMPORTANT !!IMPORTANT !!

�� Always do a bedside echo (heart/belly) when Always do a bedside echo (heart/belly) when

treatingtreating

�� Crashing patient / OHCACrashing patient / OHCA / IHCA/ IHCA

�� Regardless weather or not they got pain in the Regardless weather or not they got pain in the chest, back, or abdomenchest, back, or abdomen

�� Echo findingsEcho findings

�� AAA = aneurysm + free fluidsAAA = aneurysm + free fluids

�� AD = pericardial effusion causing AD = pericardial effusion causing tamponadetamponade

Case 2: 48 Y FemaleCase 2: 48 Y Female

�� Conscious disturbanceConscious disturbance

�� Severely dehydrated, Severely dehydrated, KussmaulKussmaul respirations (RR 36), respirations (RR 36), BP 90/60, PR 120, BP 90/60, PR 120, afebrileafebrile

�� F/S: highF/S: high

�� ABGsABGs: pH 7.08, HCO3=8, PCO2=18: pH 7.08, HCO3=8, PCO2=18

Case 2: 48 Y FemaleCase 2: 48 Y Female

�� Conscious disturbanceConscious disturbance

�� Severely dehydrated, Severely dehydrated, KussmaulKussmaul respirations (respirations (RR 36RR 36), ), BP 90/60, PR 120, BP 90/60, PR 120, afebrileafebrile

�� F/S: highF/S: high

�� ABGsABGs: pH 7.08, HCO3=8, PCO2=18: pH 7.08, HCO3=8, PCO2=18

�� MxMx: Fluid boluses, blood routine, : Fluid boluses, blood routine, ketoneketone, , OsmOsm, ECG, , ECG, CXRCXR……

�� 家屬：病人睡著了，家屬：病人睡著了，RR 12RR 12

Case 3: 48 Y Female (Case 3: 48 Y Female (續續續續續續續續))

�� 叫不醒，叫不醒，RR 12, lip cyanosisRR 12, lip cyanosis

�� On On endoendo (RSI with (RSI with EtomidateEtomidate + + RocuroniumRocuronium) ) and MVand MV�� A/C mode, RR 14, TV 500, FiO2 100%A/C mode, RR 14, TV 500, FiO2 100%

�� Few minutes laterFew minutes later……�� bradycardiabradycardia followed by followed by asystoleasystole

�� 開始開始 CPR !CPR !

�� What happened ?What happened ?

AcidosisAcidosis

�� Severe metabolic acidosisSevere metabolic acidosis

�� E.g. pH 7.08, HCO3=8, PCO2=18; which is normal?E.g. pH 7.08, HCO3=8, PCO2=18; which is normal?

�� RR 36 orRR 36 or

�� RR 14 ?RR 14 ?

�� Causes of severe acidosisCauses of severe acidosis

�� DKADKA

�� Aspirin overdose Aspirin overdose –– tends not to tends not to intubateintubate!!

�� Severe sepsisSevere sepsis

�� Asthma/COPDAsthma/COPD

AcidosisAcidosis

�� Severe acidosis Severe acidosis 做做 RSI + MV RSI + MV 要注意的重點：要注意的重點：

�� RSI RSI 盡可能用盡可能用 succinylcholinesuccinylcholine

�� If paralyzed, set RR to that prior to If paralyzed, set RR to that prior to respresp fatiguefatigue

�� If pt crashed just after MV, check DOPES:If pt crashed just after MV, check DOPES:

��D: D: DislodgementDislodgement

��O: O: ObstructionObstruction

�� P: P: PneumothoraxPneumothorax

�� E: E: Equipment failureEquipment failure

�� S: S: Stacked breaths (PEEP)Stacked breaths (PEEP)

Case 3: 25 Y MaleCase 3: 25 Y Male

�� MBA with multiple traumaMBA with multiple trauma

�� E2M4V2, BP 70/40, E2M4V2, BP 70/40, ascitesascites(+)(+)

�� RSI RSI �� PEAPEA

�� What happened ?What happened ?

BaggingBagging

�� Almost always Almost always �� bag too fastbag too fast

�� 非正式統計：非正式統計：56/min for 56/min for 生手生手

�� HypovolemiaHypovolemia + hyperventilation+ hyperventilation

�� BP dropBP drop

�� CPR + CPR + hyperventilationhyperventilation

�� Cardiac output decreaseCardiac output decrease

BaggingBagging

�� If pt crashed just after MV, check DOPES:If pt crashed just after MV, check DOPES:

�� D: D: DislodgementDislodgement

�� O: O: ObstructionObstruction

�� P: P: PneumothoraxPneumothorax

�� E: E: Equipment failureEquipment failure

�� S: S: Stacked breaths (PEEP)Stacked breaths (PEEP)

BaggingBagging

�� 重點：重點：

�� AmbuAmbu bagging bagging ��〝〝Slow downSlow down…… slow downslow down……〞〞ifif�� HypovolemiaHypovolemia

�� Cardiac arrestCardiac arrest

�� Vigorous volume replacementVigorous volume replacement

�� Smaller TV (6~8 cc/kg)Smaller TV (6~8 cc/kg)

Effective CPR: CompressionEffective CPR: Compression

�� CPR CPR –– why why 30:230:2 and not 15:2 ?and not 15:2 ?�� OHCA study OHCA study –– no no prehospitalprehospital chest compression chest compression 43% of the time43% of the time

�� IHCA study IHCA study –– commonly compression rate < commonly compression rate < 100/min 100/min

�� if >100/min if >100/min �� 75%survival75%survival

�� if < 100/min if < 100/min �� 42% survival42% survival

�� 15:2 ratio 15:2 ratio –– cannot achieve 100/min, only ~60/min cannot achieve 100/min, only ~60/min (26 s hands(26 s hands--off time)off time)

�� 結論：結論：””Push hard, push fast!Push hard, push fast!””

民眾依15:2 進行CPR 時，病患真能獲得血流循環的時間小於一半

CPR 時心臟可能並未直接受到壓擠，而是靠胸腔內壓變化造成血液循環!所以胸外按壓鬆手時一定要讓胸廓完全回彈

2000年：100下; 15:22005年：100下; 30:22010年：至少100下; 30:2

Effective CPR: DefibrillationEffective CPR: Defibrillation

�� If VF > 4~5 minIf VF > 4~5 min

�� CPR 2 min before CPR 2 min before defibdefib

�� Avoid stacked shocks, shock only once with 360J Avoid stacked shocks, shock only once with 360J

(max energy if biphasic)(max energy if biphasic)

�� CPR 2 min just after CPR 2 min just after defibdefib before pulse checkbefore pulse check

Effective CPR: DefibrillationEffective CPR: Defibrillation

�� Biphasic waveform Biphasic waveform –– mythmyth�� ACLS 2000 ACLS 2000 –– recommendedrecommended

�� AHA 2005 AHA 2005 –– though lower current, but not better though lower current, but not better than than monophasicmonophasic

Effusion and EmbolismEffusion and Embolism

�� Pericardial effusionPericardial effusion and and pulmonary embolismpulmonary embolism

�� Both haveBoth have……

�� SOBSOB

�� ShockShock

�� PEAPEA

�� Clear breath soundsClear breath sounds

�� Distended neck veinsDistended neck veins

�� Risk: malignancy, pregnancyRisk: malignancy, pregnancy

Pulmonary embolism

Pulmonary embolism: Diagnosis

Pulmonary embolism: Diagnosis

Pulmonary embolism: Diagnosis

Pulm. embolism: Management

DDxDDx: Effusion and Embolism: Effusion and Embolism

EffusionEffusion EmbolismEmbolism

CXRCXR

ABGsABGs

EchoEcho

ECGECG

FluidFluid

ETTETT

TPATPA

DDxDDx: Effusion and Embolism: Effusion and Embolism

EffusionEffusion EmbolismEmbolism

CXRCXR cardiomegalycardiomegaly no no cardiomegalycardiomegaly

ABGsABGs good O2good O2 hypoxemiahypoxemia

EchoEcho effusionseffusions distended RVdistended RV

ECGECG tachytachy + low voltage+ low voltage tachytachy + S1Q3T3 + S1Q3T3

FluidFluid BP upBP up BP dropBP drop

ETTETT BP dropBP drop BP upBP up

TPATPA NoNo YesYes

Echo: Pulmonary embolismEcho: Pulmonary embolism

Severely distended RV with septal displacement into LV

Echo: Cardiac Echo: Cardiac tamponadetamponade

Pericardial tamponade causes diastolic collapse RV

病人爆掉了怎麼辦病人爆掉了怎麼辦病人爆掉了怎麼辦病人爆掉了怎麼辦？？？？病人爆掉了怎麼辦病人爆掉了怎麼辦病人爆掉了怎麼辦病人爆掉了怎麼辦？？？？

�� Critical interval between ABC and CBCCritical interval between ABC and CBC

��急診醫師的真正考驗！急診醫師的真正考驗！

�� The golden 1 hourThe golden 1 hour

�� What should you do?What should you do?

1. Stabilize vital signs / effective CPR1. Stabilize vital signs / effective CPR

2. Consider ECG, 2. Consider ECG, ABGsABGs, Echo, Echo

Questions ?

Take home messageTake home message

��Managing crashing patient Managing crashing patient

�� Between ABC and CBC Between ABC and CBC -- golden hourgolden hour

�� Considered Considered 3A3E3A3E ::

�� 3A: 3A: AAMI, MI, aaorta, orta, aacidosiscidosis

�� 3E: 3E: EEffective CPR, ffective CPR, eeffusion, ffusion, eembolismmbolism