Thursday, 22 September 2016

Advanced Life Support

We all know how to manage cardiac arrest, as per ALS. There's always a few little things that I remember, and are good to remind ourselves of. There's also a few little things that we can do and think of as "extras".

Causes of Arrest
The 4Hs and 4Ts are commonly used, and this picture on the left (from Twitter, original source unknown) is a nice way of thinking about it.

 Pyrexia must be prohibited post-cardiac arrest. It is common in the first 48 hours and the risk of a poor neurological outcome increases with each degree rise over 37oC. Maintain normothermia - 32 to 36 degrees.












If we have PEA, it is useful for us to think "Is it wide" or "is it narrow" to help us further hone our diagnostic reasoning.











Drugs

Post ROSC Care
A MAP of about 65-100 mmHg is a reasonable starting point in most –adjusted according to response.


"Special" Circumstances 
Hypothermia:  No adrenaline until >30,
                          double time in between 30 - 35,
                          normal once >35
Drugs are often ineffective and will undergo reduced metabolism.

In primary hypothermic cardiac arrest, death should not be confirmed until:
The patient has been re-warmed
Or
Other unsurvivable injuries have been identified
Or
Re-warming has failed despite all available measures

LA OD
Intralipid
1.5ml/kg bolus AND infusion 15ml/kg / hour
After 5 min 2 further boluses if not better
And double infusion to 30m/kg/hr
Resuscitate for one hour

Lidocaine toxicity
5 Light headedness, circumoral paraesthesia, slurred speech + tinnitus
10 Convulsions, LOC
15 Coma, myocardial depression
20 Resp arrest + arrhythmia
>25 Cardiac arrest

Pregnancy
Peri-mortem c-section


References and Links
http://rebelem.com/a-new-pulseless-electrical-activity-algorithm/
http://www.rcemlearning.co.uk/modules/an-unusual-cause-of-cardiac-arrest/ 
http://www.rcemlearning.co.uk/modules/ooh-cardiac-arrest/ 
http://www.rcemlearning.co.uk/references/post-cardiac-arrest-care-of-the-rosc-patient/ 
http://www.rcemlearning.co.uk/modules/anaphylaxis-induced-cardiac-arrest/
http://www.rcemlearning.co.uk/modules/management-of-post-arrest-patients-including-prognostication/
http://www.rcemlearning.co.uk/modules/a-systematic-review-of-therapeutic-hypothermia-for-non-shockable-cardiac-arrest/
http://www.rcemlearning.co.uk/references/cardiac-arrest-in-special-circumstances-hypothermic-cardiac-arrest/
http://www.rcemlearning.co.uk/references/cardiac-arrest-in-special-circumstances-anaphylaxis/
http://www.rcemlearning.co.uk/modules/the-curious-incident-of-the-wolff-in-the-nighttime/
http://www.rcemlearning.co.uk/modules/the-resus-lottery/
http://www.rcemfoamed.co.uk/portfolio/saap-intra-aortic-adrenaline-in-cardiac-arrest/ 

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