ACLS Special Resuscitations

1. ACLS Special Resuscitations Dr. Michelle Welsford

2. Introduction • Hypothermia • Traumatic Cardiac Arrest • Electrical Shock and Lightning • Cardiac Arrest associated with Pregnancy • Toxicologic Cardiac Emergencies

3. Hypothermia • Severe hypothermia: T < 30C • Often unresponsive to defibrillation and pacemaker •  CBF and O2 requirement,  Cardiac Output,  arterial pressure • may appear clinically dead because CNS depression and CVS depression

4. Hypothermia Continued • Peripheral pulses and respiration may be difficult to detect • Take 30-45 seconds to confirm pulselessness or profound bradycardia • Bradycardia is usually physiologic and pacing not indicated until warmed • V fibrillation • Try 3 shocks but may be unsuccessful until rewarmed • Can repeat defib when temperature rises > 32 C

5. Hypothermia Continued • Handle gently to avoid precipitating v. fib • Intubate gently; Avoid NG, pacer, etc • Warming • “warm and dead” – try to rewarm to 34 C but use judgment • if dead – wont’ be able to warm completely • External warming • Internal warming

6. Hypothermia Continued • Metabolism of medications is slowed • < 30 C - only one round of medications • > 30 C usual meds but at greater intervals • Bretylium – ? DOC in hypothermic V fib because raises fibrillation threshold

7. Traumatic Cardiac Arrest • Don’t need to begin resuscitation if: • Hemicorporectomy • Decapitation • Total body burns • Obvious severe blunt trauma without vital signs • Deep penetrating cranial injuries • Penetrating injuries, asystole and transfer time > 15 minutes to trauma centre

8. Blunt Trauma Cardiac Arrest • Exsanguinations often difficult to treat • Survival nearly nil except: • Ventilate high spinal cord injury • Clear Airway obstruction • Relief of Tension pneumo • Fluid/Blood resuscitation of single organ injury • Defibrillation of VF that may have caused trauma

9. Penetrating TraumaArrest • Directly to trauma centre if < 15 minutes from arrest • Intubation • IV en-route • In general, don’t worry about meds/defib • Rapid fluid resuscitation after control of hemorrhage surgically

10. Electrical Shock & Lightning • Alternating current: • Ventricular fibrillation common • Direct current: • Asystole common

11. Electrical Shock & Lightning Continued • Respiratory arrest may be prolonged long after cardiac rhythm restored • Respiratory arrest secondary to: • Inhibition of central medullary respiratory centre • Tetanic contraction of the diaphragm and chest wall musculature during current exposure • Prolonged paralysis of respiratory muscles • With electic/lightning injuries - use reverse triage and treat nonbreathing, pulseless patients first

12. Electrical Shock & Lightning Continued • Management: • Ensure safety • CPR –young, healthy people may have good survival even after as long as 1 hour of CPR • Ventilation • Treat burns: • Lightning: rarely have cutaneous/muscle injury • Electric: often have cutaneous burns, muscle, etc • Myoglobinuria will require fluid resuscitation +/- bicarbonate

13. Cardiac Arrest in Pregnancy • Physiologic changes in pregnancy •  Maternal CO by up to 50% •  HR, minute ventilation, O2 consumption •  Pulmonary functional residual capacity, systemic and pulmonary vascular resistance • less tolerant to respiratory and cardiovascular insults • when supine, gravid uterus may compress inferior vena cava and abdominal aorta resulting in hypotension and  in CO (by 25%)

14. Cardiac Arrest in Pregnancy Continued • Precipitants of cardiac arrest: • pulmonary embolus • amniotic fluid embolus • trauma • peripartum hemorrhage • congenital and acquired cardiac disease • complications of tocolytic therapy including arrhythmia, CHF, AMI

15. Cardiac Arrest in Pregnancy Continued • Management: • standard resuscitation followed • if VF then defibrillation • CPR as usual, Meds as usual • Wedge under Right hip to displace uterus to left

16. Cardiac Arrest in Pregnancy Continued • Potential fetal viability up to 20 minutes, best if < 5 minutes • If no maternal response within 4 minutes, then should consider perimortem C-section (if in neonatal center) • Delivery within 4-5 minutes of arrest • May result in viable fetus/infant; best survival for mother

17. Toxicologic Cardiac Emergencies – Cocaine • Physiology: • Stimulates release and blocks reuptake of NE, E, dopamine and serotonin •  BP,  HR, euphoria, CNS stimulation,  myocardial contractility, coronary artery spasm, seizures, death •  coronary artery flow due to spasm and  O2 consumption leading to cardiac ischemiaHTN and SVT

18. Cocaine Continued • Management: • HTN • O2 and diazepam, nitro/nitroprusside, Labetalol; not B-blockers! • PSVT, A fib, A flutter • O2 (don’t usually require treatment because short-lived) • if persistent, often responds to benzos eg: Diazepam: blunts hypersympathetic state centrally

19. Cocaine Continued • ventricular irritability –runs of VT, PVCs • O2, benzos, lidocaine, B-blocker • often transient but may require benzos if continue eg: VT • standard ACLS with LIDO but may increase risk of seizures • selective B1-blockers may be better (esmolol)

20. Cocaine Continued • Ventricular fibrillation • Standard ACLS except increase interval between epi and avoid high dose epi • Lidocaine 1 dose only • If non-responsive try selective B-blocker • Magnesium

21. Cocaine Continued • AMI • Treat with benzodiazepines and nitroglycerin • B-blockade causes unopposed alpha stimulation so avoid • Ischemia/infarction may be due to spasm, therefore angioplasty may be better than thrombolysis

22. Toxicologic Cardiac Emergencies – TCAs • One of the most cardiotoxic medications • Sinus tach, prolonged QT widened QRS, hypotension, ventricular arrhythmias, VT, torsades, seizures • Management: • Alkalinization:Ph 7.45-7.55 with bolus NaHCO3 • Decrease free unbound form and overrides the Na-channel blockade of phase I action potential • Avoid procainamide; may use lidocaine if necessary (true VT)

23. Summary • ACLS guidelines for majority of arrhythmias and resuscitations • Some special resuscitations require deviation from guidelines

24. Questions ?