szewii L. @szewii on GrepMed

ACLS 2015 Algorithm for Cardiac Arrest #Management #EM #Prehosp #ACLS #2015 #Algorithm #ALiEM

Week 2 – Adult Advanced Life Support Algorithm - Strata5 @Nrtaylor101 #Management #ACLS #LifeSupport #Algorithm #HsTs #HTs

The Society of Thoracic Surgeons protocol poster for the resuscitation of patients who arrest after cardiac surgery. #Management #PostCardiac #Surgery #Arrest #CPR #Algorithm #ACLS

Paediatric Arrest - Strata5 @Nrtaylor101 #Peds #Paediatrics #Pediatrics #Management #ACLS #PALS #Arrest #Advanced #LifeSupport #WETFLAG #Mnemonic #Algorithm

REBEL Review 95: Treatment of Eclampsia #eclampsia #management #obgyn #hypertension #treatment #medications #obstetrics

Cardiac Arrest - Guidelines for Crises in Anaesthesia The probable cause is one or more of: something related to surgery or anaesthesia; the patient’s underlying medical condition; the reason for surgery; equipment failure. The first priority is to start chest compressions, then get help, then find and treat the cause using the guideline. ❶ IMMEDIATE ACTION • Declare “cardiac arrest” to the theatre team AND note time. • Delegate one person (minimum) to chest compressions 100 min-1, depth 5 cm. • Call for help: nearby theatres / emergency bell / senior on-call / dial emergency number. • Call for cardiac arrest trolley. • As soon as possible, delegate task of evaluating potential causes (Box A). ❷ Adequate oxygen delivery • Increase fresh gas flow, give 100% oxygen AND check measured FiO2. • Turn off anaesthetic (inhalational or intravenous). • Check breathing system valves working and system connections intact. • Rapidly confirm ventilator bellows moving or provide manual ventilation. ❸ Airway • Check position of airway device and listen for noise (including larynx and stomach). • Confirm airway device is patent (consider passing suction catheter). • If expired CO2 is absent, presume oesophageal intubation until absolutely excluded. ❹ Breathing • Check chest symmetry, rate, breath sounds, SpO2, measured expired volume, ETCO2. • Evaluate the airway pressure using reservoir bag and APL valve. ❺ Circulation • Check rate and adequacy of chest compressions (visual and ETCO2). • Encourage rotation of personnel performing compressions. • If i.v. access fails or impossible use intraosseous (IO) route. • Check ECG rhythm for no more than 5 seconds. • Follow Resuscitation Council (UK) and ERC Guidelines. • See Boxes B and C for reminders about drugs and defibrillation. ❻ Systematically evaluate potential underlying problems and act accordingly (Box A). ❼ If there is return of spontaneous circulation, re-establish anaesthesia. POTENTIAL CAUSES 4 H’s, 4 T’s: Hypoxia (→ 2-2) Hypovolaemia Hypo/hyperkalaemia Hypothermia Tamponade (→ 3-9) Thrombosis (→3-5) Toxins Tension pneumothorax Specific peri-operative problems: Vagal tone Drug error Local anaesthetic toxicity (→ 3-10) Acidosis Anaphylaxis (→ 3-1) Embolism, gas/fat/amniotic (→ 3-5) Massive blood loss (→ 3-2) By Association of Anaesthetists @ https://twitter.com/AAGBI Quick Reference Handbook - Guidelines for crises in anaesthesia #CardiacArrest #Checklist #Differential #Anesthesiology #Anesthesia #Intraoperative #Checklist #Diagnosis #Management #Workup

Intraoperative Anaphylaxis - Guidelines for Crises in Anaesthesia • Unexplained hypotension • Unexplained bronchospasm (wheeze may be absent if severe) • Unexplained tachycardia or bradycardia • Angioedema (often absent in severe cases) • Unexpected cardiac arrest where other causes are excluded • Cutaneous flushing in association with one of more of the signs above (often absent in severe cases) ❶ Call for help. Note the time. Stop or do not start non-essential surgery. ❷ Call for cardiac arrest trolley, anaphylaxis treatment pack and investigation pack. ❸ Remove all potential causative agents and maintain anaesthesia. • Important culprits: antibiotics, neuromuscular blocking agents, patent blue. • Consider chlorhexidine as cause (impregnated catheters, lubricants, cleansing agents). • Consider i.v. colloids as a possible cause. • Change to inhalational anaesthetic agent (if not already). ❹ Give 100% oxygen and ensure adequate ventilation: • Maintain the airway and, if necessary, secure it with tracheal tube. ❺ Elevate patient’s legs if there is hypotension. ❻ If systolic blood pressure < 50 mmHg or cardiac arrest, start CPR immediately. ❼ Give drugs to treat hypotension (Box A): • Hypotension may be resistant and may require prolonged treatment. • Give adrenaline bolus and repeat as necessary. • Consider starting an adrenaline infusion after three boluses. • If hypotension resistant, give alternate vasopressor (e.g. metaraminol, noradrenaline infusion +/ vasopressin) • Give glucagon in ß-blocked patient unresponsive to adrenaline. ❽ Give rapid i.v. crystalloid: 20 ml.kg-1 initial bolus, repeated until hypotension resolved. ❾ Give hydrocortisone as part of resuscitation (Box B). ❿ If bronchospasm is persistent, consider → 3-4 ⓫ Take 5-10 ml clotted blood sample for serum tryptase as soon as patient is stable. • Plan for repeat sample at 1-2 hours and >24 hours. ⓬ Give chlorphenamine when feasible (Box B). ⓭ Plan transfer of the patient to an appropriate critical care area. Note tasks in Box D. ⓮ Prevent re-administration of possible trigger agents (allergy band, annotate notes/drug chart) By Association of Anaesthetists @ https://twitter.com/AAGBI Quick Reference Handbook - Guidelines for crises in anaesthesia #Anaphylaxis #Anesthesiology #Anesthesia #Intraoperative #Checklist #Diagnosis #Management #Workup

Intraoperative Massive Blood Loss - Guidelines for Crises in Anaesthesia Expected or unexpected major haemorrhage ❶ Call for help, inform theatre team of problem and note the time. ❷ Increase FiO2 and consider cautiously reducing inhalational/intravenous anaesthetics. ❸ Check and expose intravenous access. ❹ Control any obvious bleeding (pressure, uterotonics, tourniquet, haemostatic dressings). ❺ Call blood bank (and assign one person in theatre to liase with them): • Activate major haemorrhage protocol. • Communicate how quickly blood is required. • Communicate how much blood and blood product is required. ❻ Begin active patient warming. ❼ Use rapid infusion and fluid warming equipment. ❽ Discuss management plan between surgical, anaesthetic and nursing teams: • Liaise with haematologist if necessary (Box A). • Consider interventional radiology. • Consider use of cell salvage equipment. ❾ Monitor progress: • Use point of care testing: Hb, lactate, coagulation, etc. • Use lab testing: including calcium and fibrinogen. ❿ Replace calcium and consider giving tranexamic acid (Box C). ⓫ If bleeding continues consider giving recombinant factor VIIa: liase with haematologist. ⓬ Plan ongoing care in an appropriate clinical area. By Association of Anaesthetists @ https://twitter.com/AAGBI Quick Reference Handbook - Guidelines for crises in anaesthesia #BloodLoss #Hemorrhage #Anesthesiology #Anesthesia #Intraoperative #Checklist #Diagnosis #Management #Workup

Local Anaesthetic Toxicity - Guidelines for Crises in Anaesthesia Signs of severe toxicity: • Sudden alteration in mental status, severe agitation or loss of consciousness, with or without tonic-clonic convulsions. • Cardiovascular collapse: sinus bradycardia, conduction blocks, asystole and ventricular tachyarrhythmias may all occur. • Local anaesthetic toxicity may occur some time after an initial injection. ❶ Stop injecting the local anaesthetic (remember infusion pumps). ❷ Call for help and inform immediate clinical team of problem. ❸ Call for cardiac arrest trolley and lipid rescue pack. ❹ Give 100% oxygen and ensure adequate lung ventilation: • Maintain the airway and if necessary secure it with a tracheal tube. • Hyperventilation may help reduce acidosis. ❺ Confirm or establish intravenous access. ❻ If circulatory arrest: • Start continuous CPR using standard protocols. • Give intravenous lipid emulsion (Box A). • Recovery may take >1 hour. • Consider the use of cardiopulmonary bypass if available. If no circulatory arrest: • Conventional therapies to treat hypotension, brady- and tachyarrhythmia. • Consider intravenous lipid emulsion (Box A). ❼ Control seizures with small incremental dose of benzodiazepine, thiopental or propofol. By Association of Anaesthetists @ https://twitter.com/AAGBI Quick Reference Handbook - Guidelines for crises in anaesthesia #Local #Anaesthetic #Toxicity #Anesthesiology #Anesthesia #Intraoperative #Checklist #Diagnosis #Management #Workup