Tag: als

SMS Teaching: Traumatic Cardiac Arrest

Here’s the video from March 2018’s consultant education, on the theme of traumatic arrest.

It includes a case discussion of a gunshot wound to the chest in a young women with cardiac arrest, a talk on the management of traumatic arrest and the utility of CPR, and finally a discussion on ED thoracotomy.

The quality’s not great and we lost the AV halfway through, so I’ve patched in a PowerPoint presentation of the second part.

There’s also a video from the Alfred procedures course on thoracotomy- please don’t distribute this further, as it’s released to candidates on the course only.

Hope you enjoy, please post any comments or questions and we’ll attempt to answer them.

Thanks.

Further reading:

EMCrit

EMRAP – the quiet chest in trauma

ANZCOR guidelines

St Emlyn’s – CPR in TCA?

Pericardiocentesis in Cardiac Tamponade

Cliff Read recently put out a great post on this issue.

The take home points:

  1. Perform when refractory shock with evidence of tamponade physiology on ECHO:

A large effusion with a ‘little invisible man using the RV as a trampoline”

  1. Remove only small volumes of blood at a time (e.g. 30mls), aiming for a SBP of 90 mmHg.

The danger is overshooting the BP, resulting in hypertension and extension of the dissection which can be fatal.

  1. Avoid intubation if possible until a surgeon is ready to cut – positive pressures lead to worsening tamponade physiology (although mitigated by pericardiocentesis).
  2. Other options include intubation under local anaesthesia, allow the patient to breathe spontaneously through the tube, or preloading with fluid, using cautious doses of induction agent, and ventilating with low pressures & zero PEEP.
  3. CPR is futile in arrested patient.
  4. CPR leads to lower MAP and diastolic pressures, therefore worsening coronary perfusion. Only relief of tamponade will provide a chance of recovery.
  5. Patients requiring transport should be accompanied by a clinician able to perform pericardiocentesis in the event of deterioration en route.

The kit:

The approach:

There are several approaches – subxiphoid, left parasternal, apical. Go where the most blood is.

Thanks,

Stacy

 

If they arrest To intubate or not to intubate?

CPR or no CPR?

How to transfer – physician escort or just send in an ambulance on lights and sirens?

 

https://www.youtube.com/watch?v=nWJxZco6oCw

 

Winter’s Wrap 25/1/17 – PEA + PE, Tibial plateau fractures, Breakfast

Summary of teaching 25/1/17 – DEMT Karen Winter

 

PE, thrombolysis and PEA arrest 

Elliott Adamson presented on the PEAPETT study  which suggested that thrombolysis in PEA arrest where PE was confirmed had benefit. This was contrasted with other studies of PEA arrest without clear cause where benefits of thrombolysis were much less obvious.

Review his talk here.

 

Tibial plateau fractures 

Emily Hunter presented an audit of missed tibial plateau fractures and a guide to reviewing injuries of the knee.

  • Push for advanced imaging (CT) if the mechanism of injury is suspicious and if the patient is unable to mobilise
  • Look for the subtle signs eg. lipohaemarthrosis and tibio-femoral alignment
  • Treat suspected or proven tibial plateau fractures with non-weight bearing and zimmer knee splint, with orthopaedic follow-up
  • Call radiology if unsure about the plain films!

Review her talk here.

 

Put this in your breakfast! 

Karen Winter reflected that, just as you wouldn’t miss certain steps in getting ready to go to work (shower, toothbrush, coffee x 2), there were other more intangible things important not to forget in your pre-shift preparation (empathy, diligence, curiosity).

 

 

 

 

 

Thrombolysis in PEA arrest and PE

Thrombolysis in PEA with confirmed PE

 

Thanks Elliott Adamson for this presentation about the PEAPETT study.

Key points:

  1. Suggests that thrombolysis with tPA in PEA arrest with confirmed PE has benefit
  2. Logically contrasts with other studies of thrombolysis in PEA arrest (all causes) which does not appear to show particular benefit
  3. Despite minimal proven benefit of thrombolysis in PEA arrest where cause is unclear, consideration of thrombolysis is still important (reversible causes – 4Hs and 4Ts) particularly in younger patients where overall outcome likely to be better

New ANZCOR resus guidelines

ANZCOR have updated their guidelines.

The main changes – as summarised by Dr Stacy Turner:

ALS
Defibrillation – can increase 2nd shock energy to maximum available on defib, if first shock unsuccessful.
Cooling anywhere between 32-36 degrees.
Post-ROSC PCI – immediate in STEMI, new LBBBB and selected patients if coronary ischaemia is considered the likely cause on clinical grounds (although Level of Evidence III – poor)

BLS
Chest compressions now 100-120/min instead of 100

Neonatal
For term babies, start with air, not oxygen; for pre-term babies start at 21-30% O2, then titrate O2 to sats (minimum at 1min 60%, 2min 65%, 3min 70%, 4min 75%, 5min 80%, 10min 85%)

Paediatric
Chest compressions now 100-120/min instead of 100
Cooling anywhere between 32-36 degrees post ROSC

First Aid
C-spine collars for suspected spinal injuries by any first aid provider in the pre-hospital environment no longer recommended