SPECIAL SITUATIONS IN CPR

Special circumstances

• Common cause of • cardio-respiratory arrest in young• Cardiac arrest could be often

prevent• Some patients require prolonged

resuscitation

HypothermiaDefinition:Core temperature <35 ° C(thermometer reading low

temperature)

Light 32 to 35 ° CAverage 30 to 32 ° CSevere <30 ° C

Special problems: immersion extreme ages injury / illness Drugs / alcohol

Hypothermia

Clinical features of hypothermia

• Pulse: slow, irregular, filiform• TA: low or unmeasured• Pupil: dilated• CNS: altered mental status, coma• Hypothermia is primary or secondary ?

Atention !• Clinical features of hypothermia may mimic

death• Effect of brain protection• "The patient is not dead until it is warm and

dead", except that:• fatal injuries are obvious• body is so frozen that resuscitation is

impossible

Airways and breathing

• Oxygen in high concentration, humidifier and heated (40-46 ° C)

• Tracheal intubation under ACLS algorithm

• Ventilation observe chest rise

Breath• Oxygen in high concentration • Intubation unconscious patients• Arterial blood gas analysis (Astrup

arteriosus)• IOT - rapid induction cricoidian

pressure (requiring specialists)

Circulation

• Notice the extreme bradycardia• Consider the Doppler examination• Oesophageal temperature• Thoracic stiffness is increased• Central veins or proximal to large size

Arrhythmias associated with hypothermia

Sinus bradycardiaAtrial fibrillation TemperatureFibrillationAsistolie

Circulation• Defibrillator may fail if core temperature

is> 30 ° C• Other types of arrhythmias are

spontaneous improved, while increasing temperature

• The efficacy of drugs is reduced to a temperature <30 ° C

• Bradycardia may be physiological in severe hypothermia

Patient Warming

• Remove patient from cold environment

• Mobilization may precipitate the emergence of arrhythmias

• Prevent further heat loss• Quickly transported patient to

hospital• Remove clothes cold / wet

Active heatingExternal Blankets with hot air Heated ChamberInternal Extracorporeal circulation Ventilation with 02 heated and Humidifier Hot fluid i.v. (40 º C) Gastric lavage, peritoneal, pleural and

bladder with warm liquid Continuous veno-venous haemofiltration

Monitoring and investigations

• Continuous hemodynamic monitoring• Repeated blood gas analysis• do not use temperature correction !• Electrolytes• hyperkalaemia during heating• Thyroid function (elderly)

Immersion and submersion• Immersion - head above water

• hypothermia• cardiovascular instability

• Submersion - head in the water– asphyxia– hypoxia - secondary cardiac

• Drowning-death within 24 hours of submersion

Resuscitation decision• Complete return is possible

even after a prolonged immersion

• Increased risk of hypothermia if the water temperature <25 ° C

• Submersion due to seizures or alcohol?

Saving from water

• Minimize risk of rescuers• Suspected of spine injury• Keeping the patient in horizontal

position• Do not start resuscitation in the water

unless you are trained for this

Airways and breathing

• Caution: possible spine injury• Administer 100% oxygen• Do not try to "Drain the lungs"• Vomiting is common• Early intubation if the patient is

unconscious

Airways and breathing• Ventilation should be initiated as soon as

possible, safely for rescuer (in shallow water or ashore)

• It opens air ventilation and administered for 1 minutes

• If the victim can be brought to shore in less than 5 min. continue vents

• If the distance is bigger vent 1 minutes and try to bring faster the victim to shore without the other breaks for ventilation

Circulation • Notice the extreme bradycardia• "Hypovolemia" caused by the

removal of hydrostatic pressure exerted by water on the body during immersion

• Intravenous fluids• Nasogastric tube• No matter if the phenomenon

occurred in fresh / salt

Investigations

–Astrup artery–Electrolytes–Blood sugar–ECG–Rx. lung

Poisoning• One of the main causes of death in people

under 40 years• The most common are voluntary poisoning

with drugs or drug agents• Industrial accident or exposure during war:• chemical contamination• radiation

Resuscitation: airways• Altered state of consciousness is usually in the

case:– airway obstruction

• respiratory arrest• Avoid mouth-to-mouth for poisoning with:

– cyanide– Hydrogen sulphide– corrosive substances– organophosphorus

Circulation • Hypotension induced by drugs is

common• Fluid therapy + / - inotropic

medication• Acid-base imbalances• Synchronous cardioversion for life-

threatening arrhythmias

Specific antidotes• Paracetamol - N-acetilcisteină• Organophosphorus - Atropine• Cyanide - Sodium nitrite - sodium thiosulphate

- Cobalt EDTA• Digoxin - Fab Antibodies• Opioids - naloxone

Specific therapeutic measures• Limiting absorption of toxic substances

ingested• gastric lavage <1hr• activated charcoal• bowel irrigation• Growth removal

– hemodialysis– hemoperfusion

• Specific antidotes

Management

• Prolonged coma-rhabdomyolysis• Electrolytes (K +) and blood sugar• Blood gases (arterial Astrup)• Temperature

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Pregnancy: causes of cardiac arrest in pregnant

• Bleeding• Pulmonary embolism• Embolism with amniotic

fluid • Detachment of the

placenta• Eclampsia• Drug intoxication

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Resuscitation in pregnancy

• It takes two people• Early involvement of an obstetrician

and a neonatology

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Airways• Increased risk of regurgitation• Cricoidian pressure • Tracheal intubation (difficult):• thickening of neck• chest size• glottis edema

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Breath

Difficult because: Diaphragm is ascensioned and

limit his movementsIt may be necessary a high

pressure insufflation

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Circulation• The uterus flatening the inferior vena cava • Moving the uterus :

– Semidecubit left side– Manual handling

• Restoration volemiei• Immediate surgery if bleeding

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Emergency caesarean In the 3rd trimester of

pregnancy, if resuscitation is unsuccessful in the first 5

minutes

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• At a gestational age of 20-23 weeks, caesarean section will be done in order to maternal resuscitation

• At a gestational age> of 24-25 weeks, caesarean section in order to perform resuscitation of both mother and fetus

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Electrocution

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Electrocution

• Electricity (AC):• housewife• Industrial• Flash (DC)

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Factors influencing the severity

• Current type and route it through the body

• alternating (AC) - more frequent FV• continuous (DC) - more frequent

asystola• Voltage current• Current intensity delivered• Resistance to electricity• Area and duration of contact

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Lightning

• Cardiac depolarisation• asystola or FV(ventricular

fibrilation)• Paralysis of respiratory muscles

may cause respiratory arrest• Extended Neurological Injury

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Rescuer safety• Pause power source• High voltage current can:

–produce arc–to spread through the

ground

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CPR

• BLS and early ALS• Early intubation if the / neck burns

presents• Muscle paralysis may persist for

30 min after high-voltage shocks

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Anaphylaxis• Anaphylaxis - hypersensitivity reaction

mediated by IgE• Non-allergic anaphylaxis - does not

involve hypersensitivity• Similar events and treatment

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Clinical signs• Angioedema - swelling laringean• Rush (urticaria / erythema)• Hypotension• vasodilatation and increased vascular

permeability • Bronchoconstriction• Rhinitis, conjunctivitis• Abdominal pain, vomiting and diarrhea

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CPR• Removing allergen agent• High-flow oxygen• Adrenaline• Anaphylactic reaction - 0.5 mg 1:1000 i.m.

or s.c.• Severe anaphylactic shock - 0,1-0,5 mg iv

1:10.000• Fluids• Antihistamines - H1 blockers, consider

administration of H2 blockers• Hydrocortisone and inhaled beta 2 mimetic

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Attention to early relapses !

• Serious reactions triggered slow• Reactions in patients with asthma• Continue allergen absorption agent• History of biphasic reactions

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Severe Acute Asthma

• Reversible• Death is avoidable• patients require medical attention

too late• delayed medical personnel• premature discharge

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Asthma and cardiac arrest• Causes:• - Severe bronchospasm and mucus

hypersecretion• - Cardiac arrhythmias caused by hypoxia or the

administration exaggerated by beta-agonists• - Auto PEEP (positive pressure at the end

expired) in some patients intubated and mechanically ventilated - not expire all inspired air - increase in airway pressure - reduced venous return - reduces cardiac output

• - Suffocating pneumothorax usually bilateral

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Characteristics of potentially fatal asthma

• Silentium chest• Cyanosis• Bradycardia• Hypotension• Asthenia• Coma• Hypoxia, acidemie, + /-hipercarbie

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Treatment• Concentrated oxygen• Nebulisation with beta 2 mimetic• Steroids• Subcutaneous epinephrine 300 microgr• Inhaled anticholinergics, aminophylline

i.v.• Liquids

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• Mechanical ventilation only when drug therapy was not effective

• You may not obtain normalization of blood gas

Treatment

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CPR• Pulmonary ventilation difficult• mask ventilation increased gastric

dilation• Early intubation• Pneumothorax risk• Effective chest compressions is difficult

• It will consider open heart massage

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Cardiac arrest associated with trauma

Causes:Serious brain damageHypovolemia, hypoxiaDamage vital organsSuffocating pneumothoraxCardiac tamponadeMajor medical problems

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CPR in trauma• Identification and treatment of serious

injuries before installing cardiac arrest• Protect cervical spine• Hypoxia and / or hypovolemia → PEA• Oxygen, stop bleeding, fluid• Thoracothomia - resuscitation for cardiac

arrest associated with penetrating wounds

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Internal cardiac massageIndications

• Recent heart surgery• PEA after trauma• Hiperinflaţi lungs or chest rigid• During abdominal or thoracic

surgery

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Summary

• Fair treatment, performed in time can prevent cardiac arrest

• Change advanced resuscitation techniques to treat cardiac arrest occurred in special circumstances