Archive for the ‘.cardiac arrest’ Category

The Causes of Cardiac Arrest

November 23rd, 2015
by reuben in .cardiac arrest

It has been repeatedly demonstrated that the use of drugs empirically does not work in cardiac arrest. Despite this, ACLS often feels like an algorithmic march down a menu of pharmaceuticals, one drug after the next, hold compressions, ok still asystole, have we tried bicarb? Until everyone has had enough and the patient is pronounced. There are three things you can do to benefit your patient in cardiac arrest. The first is good chest compressions, which serves mostly to buy time. The second is shocking shockable rhythms, and the third is identifying and treating the cause of cardiac arrest. The use of a vasopressor in the right dose probably offers some benefit; unfortunately we can’t figure out what the right dose is and epinephrine 1 mg every few minutes is almost certainly way too much. Which drug is next keeps you busy and is the focus of how ACLS is taught, which is why it’s so dangerous: it feels right but not only does not benefit the patient, which drug is next distracts you from the most important task in cardiac arrest, which is figuring out why the patient in front of you just died, so you can offer a treatment to address it. Dysrhythmia is a central cause of cardiac arrest; as soon as a cardiac monitor is available, check a rhythm and if shockable, shock immediately. If you’re not sure if the rhythm is shockable, shock. The harm caused by an unindicated shock is trivial compared to the harm of untreated pulseless vtach or vfib. Acute coronary…

Guest post by Greg Press   The second perimortem C-section of my career happened last week. The first was almost ten years ago. While I’m hardly an expert (takes three to be an expert), I have some pointers worth sharing. The first case happened on the first day of my first job, in Houston, having just completed my ultrasound fellowship in New York. The night started with a guy shot in the right chest: intubation and chest tube. His girlfriend was brought in next, pregnant, shot in the head: perimortem c-section and neonatal intubation. The second was just the other day. It was my first code at my new job at a small hospital in Wellington, New Zealand. A young girl hanged herself, was found by family who called EMS. They found in her VFib, defibrillated, started CPR, intubated and called to warn us of her arrival. They reported she was in asystole, a bad sign for mom. They reported she was 22 weeks pregnant, a bad sign for baby. There have been a few PMCS reviews circulating recently in the EM world and I agree with most of their recommendations. But I have differing thoughts on a few points. Do not memorize the number 24. Or 23. Or 25, or whatever the gestational age your neonatologists say they can currently save premies. You are unlikely to know the precise age–the mother is generally the most reliable source for this information, but generally not in this circumstance. We understood the hanged woman to be 22-weeks…

two-page .pdf vector image .pdf zipped .jpg To appear in the March 2011 issue of EM Practice Guidelines Update. Thanks to sigrid hahn, scott weingart, kaushal shah, kit tainter, rob arntfield.

BLS and ACLS Quick & Easy

June 24th, 2010
by reuben in .cardiac arrest

Eight slides culled from my ACLS Therapeutics lecture.

Drugs don't work in cardiac arrest

December 3rd, 2009
by reuben in .cardiac arrest

confirming what we all know to be true: epinephrine in cardiac arrest only keeps earthworms up at night. in patients with an unshockable rhythm, perform quality chest compressions and secure the airway while you search for/empirically treat for the cause of the arrest.

Knee height for chest compressions

November 26th, 2009
by reuben in .cardiac arrest

Compressions should be done with bed at the level of the knees of the person doing chest compressions. Emerg Med J. 2009 Nov;26(11):807-10.

The resuscitation of a patient who is in cardiac arrest of unknown etiology in PEA or asystole proceeds with the simultaneous management of the ABCs and addressing the likely elements in the differential. Think Hs and Ts. – Hypoxia (Place LMA or ETT, provide 100% oxygen) – Hypovolemia (Bedside ultrasound for free abdominal fluid/AAA, consider a NS bolus – if suspicion for hemorrhage is high, administer uncross-matched blood) – Hypo/hyperkalemia (Consider calcium chloride, especially in the patient with suspected renal insufficiency) – Hypoglycemia (Consider D50) – Hypothermia (Warm the cold patient) – Hydrogen ion/acidosis (Consider bicarb, especially if toxicology is suspected) – Toxins (In addition to bicarb, consider empiric antidotes – cyanide kit, digibind, naloxone, intralipid) – Tamponade (Perform bedside ultrasound) – Tension pneumothorax (Perform bedside ultrasound / consider needle or tube thoracostomy) – Thrombosis (Consider thrombolysis for AMI or, especially PE) – Trauma (The entire cranium and posterior thorax should be inspected if occult trauma is entertained) Although the administration epinephrine (and, formerly, atropine) is emphasized in codes, these agents do not benefit arrested patients. Your only chance to reanimate a patient in PEA or asystole is to reverse the underlying cause. Take your own pulse, take a step back, and think Hs and Ts.