Aug 21 2019: NIV, nitrous, bradycardia, hypothermia, neck dissection, AF

Ventilator troubleshooting and Nitrous sedation
– I have attached the charts and procedures the nurse educators were using and they are also posted here:
Bradycardia and hypothermia (Adi)
1) consider the big 4 causes of resistant bradycardia
toxins, ischaemia, potassium, hypothermia
2) have a step-wise approach to bradycardia
– treat reversible causes
trial of atropine
– chemical pacing: isoprenaline or adrenaline
– electrical pacing
3) hypothermia
– there are passive and active rewarming techniques
modifications to usual resuscitation include:
gentle handling if T < 32 (risk of VF is present but necessary procedures are necessary)
adrenaline where T < 30 probably not useful
– in arrest where T = 30-35 deg double the time interval between doses of adrenaline (ie every 8 min)
Carotid and vertebral artery dissections (Keira)
– these types of dissections are rare, but potentially devastating
– remember to be thorough and specific with your neuro exam and try to “spot the difference” with every new case to every previous case of muscular neck pain you see
– when patients represent – think about changing something – “where else” do we need to go with this case?
Journal club – delayed v early cardioversion in AF (Yasmin)
– another study suggesting that rhythm control is not as important as rate control


The Lucas device performs mechanical CPR and can free up staff for other tasks during a cardiac arrest.

MICA Ambulance Victoria crew may bring the device in if an arrest is in progress; Alternately ED staff can ask for the device from CCU.

Review the relatively simple operation and setup of the device so you don’t have to figure it out under pressure.



ACLS 2.0

In 2015 the European Resuscitation Council changed their recommendations, slightly new algorithms, rates and the usual arguments about adrenaline and amiodarone. In my mind this detracts us from what is important. Scott Weingart is famous for saying we should be able to resuscitate better than a dermatologist who will attend the same ACLS course as yourself.

So how do we improve?

  1. Remove the cognitive load: We will be using our nursing staff to run the algorithms autonomously, timings, compressions, adrenaline and amiodarone  dosing. Albeit ultimate responsibility lies with the doctor team leader you will have this option to use the nursing staff to run the algorithms.
  2. ACLS does not fix the problem. While the nurses are running the algorithms you need to find the cause of the arrest and fix it. See the power point presentation below for some thoughts and ideas and what the world of FOAM has to say on the issue.
  3. Support each other and the nursing staff during an arrest and also reflect on what can be done differently next time, even if this is during the weekly scenarios that will take place.
  4. Introduce yourselves to the nursing resus team at the beginning of your shift. If you are on airway, let them know your preferences.
  5. Dont run away from sick patients, this is what we train for and you will not improve if you do not challenge yourself.


Resources in the slides: