Post resuscitation care

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Post resuscitation care

  1. 1. Post Resuscitation Care “Restart the Heart and Keep it Restarted” Dr. Rashidi Ahmad Malaysian Association of Emergency Medicine (MAEM)
  2. 2. Aim To create an awareness that post resuscitation intervention is as important as resuscitation itself To highlight the proper resuscitation care To save human lives
  3. 3. Outline Understanding post resuscitation phase & care Causes of failure post resuscitation Principles post resuscitation care Mx Discuss by an examples
  4. 4. Introduction Phases of Resuscitation: resuscitation & post resuscitation Outcome: death or ROSC Upon ROSC patient may: Awake with stable hemodynamic Remain comatose with unstable circulation Half of death occurs first 24 hrs Over 1 to 3 days: sepsis syndrome and MOF Days later; rapid deterioration → Death Post resuscitation syndrome
  5. 5. Post resuscitation syndrome Reperfusion failure Reperfusion injury Cerebral intoxication from ischemic metabolites Coagulopathy
  6. 6. CPR related injuries In a study of CPR related autopsy findings: 40% of patients had injuries related to closed chest CPR, i.e. fractured ribs, sternum, bone marrow emboli to lung, mediastinal bleeding, etc.
  7. 7. What is post resuscitation care? Post resuscitation care is referred to a period between restoration of a spontaneous circulation and transfer of patient care to another healthcare provider who assumes responsibility. In general, this period will be less than 30 minutes (CRUCIAL TIME) The immediate goal is to provide cardio- respiratory support to optimize tissue perfusion, especially to the brain.
  8. 8. Principles of Post resus Mx Avoid CPA recurrence Restore perfusion & oxygenation of regional organ & cell tissues Continuous ABCDs of Primary and Secondary surveys Evaluate and monitor neurologic functions (restoration of cerebral circulation) Support other dysfunction organs Resolve the situation that promoted CPA
  9. 9. Scenario 1 46 years old man, had severe ischemic chest pain since an hour ago. Suddenly he had pulseless ventricular tachycardia. Immediate asynchronized cardioversion reverted the rhythm. What is your next step?
  10. 10. Scenario 2 6 years old boy, near drowning Cardiopulmonary resuscitation was commenced ROSC after 45 minutes What is your next step?
  11. 11. Scenario 3 37 years old man had MVA (high velocity injury) He sustained head injury & intraabdominal injury Hemodynamic unstable While on fluid resuscitation he developed VT What is your next step?
  12. 12. Airway & respiratory system 1. Is the patient intubated? YES: rapidly assess patency, position, security, and oxygenation NO: rapidly assess the need for intubation, i.e. oxygenation, mental status, other considerations. INTUBATE if any indication for it exists.
  13. 13. Airway & respiratory system 2. All patients will receive supplemental oxygen. Assessment of adequate ventilation and oxygenation: Pulse oximetry ABG's (if already available) Physical exam (i.e. breath sounds, symmetrical chest expansion Respiratory character, skin color, midline trachea)
  14. 14. Airway & respiratory system 3. Consider mechanical impediments to adequate respiration, and pursue treatment of these when feasible: Tension pneumothorax, pneumothorax, and hemothorax Flail chest Mucous plugging Interstitial edema Improperly places endotracheal tube
  15. 15. Mechanical Ventilation Volume ventilator-assist-control or intermittent mandatory ventilation (IMV) Tidal volume = ideal weight in kg x 10 I:E ratio 1:2 or 1:1.5 Respiratory rate: 10-12 times/min Oxygen FiO2 - 1.0 (100%) Sensitivity: 2 cmH2O for assist-control Humidifier: 36° C PEEP: 5 cmH2O, increased as required
  16. 16. Circulatory system 1. Assess the status of the circulatory system: Clinical indicators: skin temperature, capillary refill, quality of pulses, level of consciousness Monitor parameters: heart rate and rhythm, BP, urine output (use of Foley catheter when available) PMH and current medications
  17. 17. Circulatory system 2. Support inadequate circulatory system: Hypotension - if there is evidence of bleeding, treat with IV crystalloids and blood products For evidence of cardiogenic shock, septic shock or spinal shock – treat appropriately Prophylactic drugs for reverted VF/VT Well function cardiac pace maker Maintain the drug infusion preferably via central line
  18. 18. General survey After stabilization of the respiratory and circulatory systems, a general survey of the entire patient should be performed. Look for a cause and precipitating causes of CA Serial exams of areas of particular concern should be performed. Serial review of vital signs Review ECG and Chest x ray Review ABG, and pH, serum electrolytes, magnesium and calcium
  19. 19. Chest X-Ray Position of endotracheal tube Position of central venous catheter Pneumothorax, hemothorax, hydrothorax Pulmonary edema, CHF Cardiac silhoutte Diaphragms Rib fracture
  20. 20. Other considerations Optimally, there should be two well-secured, functioning intravenous lines. A nasogastric tube (or orogastric) is useful to keep the stomach decompressed, especially in patients receiving positive-pressure ventilation. Preserve body temperature. Stop the seizure
  21. 21. Communication & documentation It is important to maintain a collaborative approach to patient care utilizing the referring physicians/nurses' report and suggestions prior to liftoff. Resus notes should include the history, assessment findings, and any treatments done by the referring EMS or hospital personnel. It is acceptable to state "see transfer notes," for particular details, and write out only the most prominent interventions.
  22. 22. Transfer Transfer to special care unit as soon as possible by senior most experience personal Support ventilation and provide oxygenation Monitor ECG, oxygen saturation and BP Prior to transport, make sure IV is secured Transport with portable monitor, defibrillator Oxygen with connections to bag-valve-system Resus drugs must accompany the patient
  23. 23. Take Home Message Resuscitated the heart, restore the brain Treat the patient, not the arrhythmia The value of unbroken Chain of Survival: Time is critical Seek and treat the cause, not just the condition

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