Special Resuscitation Situations ?????????

1
Special Resuscitation Situations?????????
Advanced Challenges in Resuscitation

• ???? ?????
• ???

2
Advanced Challenges in Resuscitation

• 1. ????????
• 2. ???????????
• 3. ???????????
• ???
• ??
• ?????
• ?????
• ???????
• ???????
• ?????

3
Advanced Challenges in Resuscitation

• ????????
• ?????????????????
• ???????????
• ???????????????
• ???????????
• ????? (Near-Fatal Asthma)
• ?????(Anaphylaxis)

4
????????

• ?????????????
• ???????????????
• ????????

5
???

• ?? gt 5.0 mEq/L
• pH ? 0.1 U ? serum K ? 0.3 mEq/L

6
?????

• Drugs (K-sparing diuretics, ACEI, NSAIDs, K
  supplements)
• ESRD
• Muscle breakdown (rhabdomyolysis)
• Metabolic acidosis
• Pseudohyperkalemia
• Hemolysis
• Tumor lysis syndrome
• Diet (rarely sole cause)
• Hypoaldosteronism (Addison disease,
  hyporeninemia)
• Type 4 renal tubular acidosis
• Other hyperkalemic periodic paralysis

7
???

• ??????(??????????) ,????
• ?????
• T???
• P???
• PR??
• QRS???

• S???
• idioventricular rhythm
• sine waves
• VF?????

8
??

• ??(5-6)?????????????????????
• ??(6-7)???NaHCO3 ?Glucose insulin?Albuterol????
• ??(gt7)????CaCl2

9
???

• ?? lt 3.5 mEq/L
• ??
• ????
• ????(????????)
• ?????????

10
???

• ??
• ????????
• ????
• ?????????
• ????
• ????

11
???

• ?????
• U?
• T???
• ST??
• ????(??digoxin???)
• PEA or Asystole

12
??

• ????????
• ????? K lt2.5 ? IV K
• ???10-20 mEq/h ECG
• ????(VF/VT)
• 2 mEq/min ? 10 mEq /5-10 min
• ???1mEq???150-400 mEq

13
???

• ?? gt 145 mEq/L
• ??
• ??????????????????????????

14
??

• ?????????
• ?????????
• ??? ?? x 0.5 x (?? - 140) /140 ? ?? x 0.4 x
  (?? - 140) /140 ?
• 70????,??160,??? ? L
• ?? ? 0.5-1.0 mEq/h (lt 12 / 24 hrs)

15
???

• ?? lt 135 mEq/L
• ????? lt120 ????
• ???????????????????????

16
??

• ????
• SIADH ?? ( 50 - 66 )
• Na deficit (desired Na - current Na) x
  0.6 x body wt (kg) ( 0.6 for men, 0.5 for
  women.)
• 3 saline 513 mEq Na/L
• ? Na 0.5 -1/hr (max. 10-15/24h)
• ???? ? pontine myelinolysis

17
?

• Na, K, Ca??????
• ????????????
• ??????? ???????

18
???

• ?? gt 2.2 mEq/L
• ????? ???
• ????
• ????
• ?????????

19
???

• ???? ???????????????????
• ?????????
• ??????????????????????

20
???

• ?????
• PR? QT ??
• QRS ??
• P?????
• T???
• Complete AV block?Asystole

21
??

• ????
• CaCl2 ( 5 to 10 mEq IV )
• ??????????
• ????
• ????
• ?????????
• IV N /S furosemide
• ????

22
???

• ?? lt 1.3 mEq/L
• ???????
• ???????????
• PTH?????
• (eg, pentamidine, diuretics, alcohol)
• ???????

23
??? - ??

• GI loss bowel resection, pancreatitis, diarrhea
• Renal disease
• Starvation
• Drugs diuretics, pentamidine, gentamicin,
  digoxin
• Alcohol
• Hypothermia
• Hypercalcemia
• Diabetic ketoacidosis
• Hyperthyroidism/hypothyroidism
• Phosphate deficiency
• Burns
• Sepsis
• Lactation

24
??? - ??

• ??????????
• ????
• ????????????????????
• ???????

25
??? - ?????

• QT ?PR ??
• ST ??
• T???
• ???? P ??????
• QRS ??
• Torsades de pointes
• VF
• ?? digitalis ??

26
??

• Severe or symptomatic hypoMg
• 1 to 2 g IV MgSO4 over 15
• Torsades de pointes
• 2 g of MgSO4 over 1 - 2
• Seizures
• 2 g IV MgSO4 over 10
• Calcium gluconate (1 g)
• ???? hypoCa
• ?????????

27
?

• 1/2 Ca in the ECF bound to alb
• Alkalosis Ca-alb binding ? ? Ca2? Acidosis ?
  Ca2?
• serum alb ? 1 g/dL ? total serum Ca ? 0.8 mg/dL
  (but Ca2?)
• In hypoalb., Ca2 may be normal
• Ca antagonizes K and Mg at the cell mem.
• Ca regulated by PTH and vit. D

28
???

• serum Ca gt 10.5 mEq/L or
• Ca2 gt 4.8 mg/dL
• Primary hyperparathyroidism and malignancy
  account for gt90 cases.

29
??? -??

• Total serum Ca ?12 to 15 mg/dL
• Neuro. S/S
• depression, weakness, fatigue, ,confusion (at
  lower levels)
• hallucination, disorientation, hypotonicity, coma
  (at higher levels)
• Renal concentration of urine

30
??? -??

• CV S/S variable
• lt 15 to 20 myocardial contractility ?
• gt 15 to 20 myocardial depression
• Automaticity and ventricular systole is shortened
  
• Arrhythmias ( refractory period ? )
• Digitalis toxicity is worsened
• Hypertension
• Many patients with hyperCa develop hypoK

31
??? -??

• GI S/S
• dysphagia
• constipation
• peptic ulcers
• pancreatitis
• Renal S/S ability to concentrate urine ?
• dehydration
• diuresis (loss of Na, K, Mg, and P? vicious
  circle of Ca reabsorption)

32
??? -?????

• QT??
• PR and QRS ??
• QRS voltage ??
• T-wave?????
• Notching of QRS
• AV block

33
??

• Symptomatic or gt15 mg/dL
• NS at 300 to 500 mL/h
• --????200 to 300 mL/h
• After adequate rehydration NS at 100 to 200 mL/h
  
• Closely monitor K Mg
• Heart F. or Renal I. hemodialysis
• Extreme conditions chelating agents
• PO4 50 mmol/8-12 h or
• EDTA 10 to 50 mg/kg/4 h

34
??(II)

• Lasix (1 mg/kg IV)
• controversial
• heart failure required
• ? reuptake of Ca from bone
• Reduce bone resorption
• calcitonin
• glucocorticoids

35
???

• serum Ca lt 8.5 mEq/L or Ca2 lt 4.2 mg/dL
• Causes
• toxic shock syndrome
• abnormalities in Mg
• tumor lysis syndrome
• rapid cell turnover
• hyperK, hyperP, and hypoCa

36
??? - ??

• Occur when Ca2 lt 2.5 mg/dL
• Paraesthesia
• Muscle cramps, carpopedal spasm
• Stridor
• Tetany
• Seizures
• Hyperreflexia
• Chvostek and Trousseau signs
• Cardiac contractility?, heart failure

37
??? - ?????

• QT??
• ??T???
• Heart blocks
• VF

38
??

• ??,???
• 10 Ca gluconate IV 10
• IV drip 0.5 to 2.0 mg/kg/hr in D5W
• ???? Q4-6H
• ???? 7-9 mg/dL
• ?? Mg, K, and pH

39
???????????

• ???????????????I-223
• ??????
• ??????
• ???????
• ?????
• VT ? VF
• ????(QRS ??)
• ??
• ????

40
?????????

• ???????????????
• BZD???? flumazenil ????,???????

41
????? Heroin, Fentanyl, Methadone

• ??????
• ??????,?? naloxone (Class IIa) I-89
• ?????
• ?????Naloxone
• Naloxone 0.4-0.8mg IV or 0.8mg IM or SC
• ?? ??????????,?????

42
??????????

• Atropine
• ????????
• ?? ?????? carbamate??
• Isoproterenol
• ????,??????????????
• ?? ?-blocker??,???isoproterenol??
• Digoxin-specific Fab
• ?????cardiac glycosides?????????
• ???????????

43
??????????

• ????adenosine ????? ??????????????
• ???? diltiazem ?verapamil??????
• Benzodiazepines??
• Physostigmine anticholinergic ??
• ?-blocker

44
???????????

• ???,???????
• Benzodiazepines?????
• Nitroprusside ?????
• Labetalol ?????
• Propranolol ???

45
??????????

• ?????????????????
• Benzodiazepines?nitroglycin?????
• Phentolamine ?????(?-blocker)
• Propranolol ???
• Labetalol ??
• Intracoronary thrombolytics or coronary
  vasodilators?????????

46
?????VT ?VF

• ??????,??????
• Procainamide ?????TCA????????????
• Lidocaine ?????? ?cocaine??????
• Phenytoin ? bretylium ?????
• Torsades de pointes
• Mg?lidocaine (Class Indeterminate )?overdrive
  pacing (electrical or isoproterenol ) ?K

47
?????????(QRS ??)

• ??????VT
• ???????????????????????????VT
• Sodium bicarbonate
• pH??7.5-7.55
• ?????

48
???????

• ??????????
• ????
• Dopamine
• ??????????
• Norepinephrine or phenylephrine
• ????dobutamine?isoproterenol
• ??????????
• Ca, amrinone, glucagon, insulin, isoproterenol,
  dobutamine

49
?????????

• ???
• ???CPR ???
• ??????

50
?????Near-Fatal Asthma

• ??????????
• ???????????
• ????????????
• Auto-PEEP ? ??,?? ?
• ????? (???)
• ????????

Asthma
51
????????? - I

• O2
• ?? PaO2 ? 92 mm Hg
• High-flow mask PRN
• ???????
• ????
• ????
• ???? (hypercarbia)
• ????,??,????? (hypoxemia)

Asthma
52
????????? - II

• Nebulized ß2-Agonists
• Albuterol (salbutamol) 2.5 to 5.0 mg Q15-20 up
  to 3 times
• epinephrine or terbutaline SC
• Corticosteroids IV
• Begin in the first 30
• Methylprednisolone 40-250 mg IV (or equivalent
  hydrocortisone)

Asthma
53
????????? - III

• Nebulized Anticholinergics
• ipratropium 0.5 mg
• delayed onset (20)
• Aminophylline IV
• 2nd line
• 1/3 as potent as ß2-agonists
• loading dose of 5 mg/kg over 30-45
• followed by 0.5 to 0.7 mg/kg/hr

Asthma
54
????????? - IV

• MgSO4 IV
• ??????
• 2 to 3 g IV (1 g/min)
• Epinephrine or Terbutaline SC
• ????????
• Epinephrine 11000, (total 0.01 mg/kg)/3 Q20
• Terbutaline 0.25 mg SC Q30 up to 3 doses

Asthma
55
????????? - V

• Ketamine
• ?????
• ???????
• ??
• 0.1 to 0.2 mg/kg ? 0.5 mg/kg/hr
• Intubation bolus of 0.5 to 1.5 mg/kg,
  repeated 20 later, or 1 to 5 mg/kg/hr
• add atropine (0.01 mg/kg, min. 0.1 mg) BZD

Asthma
56
????????? - VI

• Heliox
• helium oxygen (7030)
• ???intubation
• Bilevel Positive Airway Pressure (BiPAP)
• delay or abort the need for intubation
• counteracts the auto-PEEP
• Begin with IPAP 8-10 cmH2O, EPAP 3-5
  cmH2O

Asthma
57
????

• ????
• ketamine, BZD, or barbiturate
• ????
• succinylcholine or vecuronium.
• ?? permissive hypercarbia
• ????? (powerful bronchial relaxants)
• halothane, isoflurane, enflurane, and ether
• vasodilators and myocardial depressants(except
  for ether)

Asthma
58
????

• Extracorporeal membrane oxygenation (ECMO)
• ?????
• Ketamine IVF
• for status asthmaticus
• mild bronchodilator effect
• not cause vasodilatation, circulatory collapse,
  or myocardial depression.

Asthma
59
?????

• ????
• Primary
• Visualize vocal cord
• 5-point auscultation
• watch chest rise
• condensation in tube
• Secondary
• end-tidal CO2
• esophageal detector device
• pulse oximetry
• capnometers or capnographs
• Albuterol 2.5-5.0 mg ?????

Asthma
60
???

• Permissive hypercapnia
• Adequate sedation and paralysis
• 100 O2
• Rate 8-10/min, to avoid auto-PEEP
• Tidal volume 5 to 7 mL/kg
• Peak flow 60 L/min with a decelerating pattern

Asthma
61
???

• ??Auto-PEEP ???
• ????????????
• ???????(lt1 min)
• ??????

Asthma
62
????? Anaphylaxis

• ??
• Insect stings
• Drugs, and toxins, vaccines
• Contrast media
• Some foods (milk, eggs, fish, shellfish, peanut
  and tree nut. )
• Latex-associated anaphylaxis
• Exercise-induced anaphylaxis
• Idiopathic

Anaphylaxis
63
????? - ??

• ???? - ????
• ???? - ??
• ?????????
• ???,??,???,??,??,??
• ???????

Anaphylaxis
64
????????? - I

• ??????????????
• O2 ???
• ??,????????
• ??????
• ??????
• Epinephrine
• IM 0.3 to 0.5 mg (11000) Q5-10
• IV (110 000 10 mL) 1-5 mL over 5 minutes
• (????????)
• IVF 1-4 ?g/min
• SC ???????

Anaphylaxis
65
????????? - II

• Antihistamines diphenhydramine 25 mg IV or IM
• H2 blockers cimetidine 300 mg PO, IM, or IV
• ???? NS 1-2 L??4L
• albuterol ipratropium inhalation
• Corticosteroids ??? IV or IM
• Glucagon ?? ?-blockers?, 1-2 mg IM or IV
• Q5 min
• ????24??

Anaphylaxis
66
???????? - I

• ????????
• Fiberoptic tracheal intubation
• Needle cricothyrotomy transtracheal ventilation
• ?????? 2 - 4L
• Epinephrine??? IV
• 1 - 3 mg ? 3 - 5 mg ? 4 to 10 µg/min
• Antihistamines IV ????

Anaphylaxis
67
???????? - II

• Steroid ??????
• ???CPR ?
• ??????????

Anaphylaxis