2. A recent NEJM study on the use of hypothermia
in children after cardiac arrests showed that
hypothermia resulted in a 30 % higher survival
[38 % vs 20 % survival] and a 70 % higher
likelihood of a good neurological outcome than
normothermia.
•Cooling slows metabolic demands , each
degree Celsius reduces the metabolic rate by 7
% . It will also decrease intracranial pressure and
decrease the heart rate.
3. Pregnancy and Cardiac Arrest
• Cardioversion is safe
Turn the patient on the side, you must get the
uterus off the IVC to improve blood flow
ACLS recommendations for rx doses and
defibrillation do not change
If the pregnancy is advanced [uterus at the
umbilicus] consider Csection if within 5
minutes of the arrest!
4. Oxygen
• Once again…..
• A recent article by Stub,D on STEMI patients
needs to be “aired”. The AVOID trial.
• 683 pts with suspected STEMIs,441 confirmed.
They randomized the patients to NO o2 [O2
sat >94%] or 8 L/min by face mask. They found
that those who received O2 had larger
infarcts.
5. Cochrane Database
• The Cochrane database review in 2010 and
updated in 2013 reported that there are 4
trials of AMI and O2 that looked at 430
patients and there are 17 excess deaths in the
patients rx with O2. The RR is over 3. You are
more than 3 times more likely to die if O2 is
given when you are having an acute MI if the
O2 saturation is > than 94 % [you don’t need it
] .
6. More on O2
• Other studies reveal that at cath that coronary
blood flow will decrease by 30 % with 100%
FIo2 compared to RA.
• Hyperoxia will decrease cerebral blood flow,
shown in a 1988 study.
• These studies make it clear that O2 is a
vasoactive drug and that it should be given
only to patients who need it…. Per the AHA
2010 guidelines
7. Alcohol
• The subject arises on how to determine
intoxication…..blood tests, breathalyzer etc.
“The only reliable test for determining the
level of intoxication is the physical
examination” Can you carry on a normal
conversation without slurring your words, can
you walk without ataxia, is your judgment and
insight reasonable ?
8. Tobacco
• Smokers die on average more than a decade
before nonsmokers.
• It is estimated to cause 480,000 deaths per
year [even more than cardiac arrests!] This is
1/5 of all the deaths in the US. More recently
this number has been challenged …. It is
thought that it probably causes 550,-600,000
deaths per year ! It has recently been thought
to increase breast cancer and prostate cancer
mortality.
9. End Of Life and EMS
• POLST ,physician orders for life sustaining
treatment , the replacement for DNR , may
allow us to think about how we can help this
process along. Maybe think about discussing
with nursing homes who does not need CPR ,
or DNH ,do not transport to the hospital.
maybe we should have a list . Maybe …
12. The value of ST segment elevation in lead aVR for predicting left main
coronary artery lesion in patients suspected of acute coronary syndrome.
• 400 Pts with typical chest pain
• PCI performed within 48 hours of CCU admission
• 31% had aVR STE 1 mm
• Men/Women with STE in aVR: 40.7%/43.8%
• Sens/Spec: 62.7%/73.6%
Rom J Intern Med. 2012 Apr Jun;50(2):159 64.
13. • A second article was written about this entity
by Hennings , J.R. et al. There was ST
elevation in AVR with diffuse ST depression in
many other leads. The patients had L main,
Proximal LAD or multivessels CAD with acute
coronary occlusions
14. STEMI with a LBBB
• Sgarbossa criteria: In a normal LBBB the ST
segment is in the opposite direction of the
QRS. When they are in the same direction a
STEMI is likely [70 %] . The EKG that follows
shows this.
17. • In the EKG above the V1-V3 have a
predominant S wave and the ST segments are
positive. In V5-V6 the R waves are positive and
the ST segments are negative. This is normal
in a LBBB. However if you look at leads III and
AVF there is a positive QRS and ST elevation
..they are in the same direction. This is not ok
[concordant ] . It is likely due to a STEMI
19. STEMI and LBBB
• The above EKG is another example of this
Now clearly in III and AVF there s ST elevation
and a positive QRS. This is diagnostic of a
STEMI with a LBBB. Lead V3 is also suggestive
of concordance the ST segments and the QRS
go in the same direction.
20. Shock
• We have not discussed this in a while and a
brief review seems reasonable
• Shock occurs when the body metabolic
demands exceed the supply. Mortality is high.
The time to identification can decrease
mortality . Early antibiotics for sepsis, earlier
door to balloon times for cardiogenic shock,
and early interventions with traumatic shock
patients may decrease mortality
21. Shock continued
• Classification:
• Hypovolemic: either hemorrhage or fluid
losses,
• Cardiogenic: the heart cannot maintain an
adequate cardiac output
• Distributive : normal volume, but vasodilation
results in shock
• Hypovolemia , usually hemorrhagic or volume
losses
• Obstructive : Limited cardiac filling or
increased afterload
22. More shock
• Distributive: normal volume but vascular
dilatation causes hypotension. The 3 best
examples are sepsis, neurogenic and
anaphylactic. All result from vasodilation. The
neurogenic occur with a high cervical spinal
cord injury and there is usually bradycardia
23. More on shock
• Obstructive : Tamponade resulting in minimal
venous inflow, massive pulmonary embolism
[limited RV cardiac output], and
pneumothorax [again limited venous input]
24. Shock
• Examination: start with the usual suspects –
primary survey. Assess that the airway is
intact, and that the patient is ventilating the
lungs.If there are absent BS then a
pnemothorax or large effusion may be the
cause.
• If there are signs of hemorrhage address
these with pressure and potentially
tourniquets . If pressure and tourniquets
cannot be used , in areas like the axilla then
Quickclot may be useful.
25. Shocking continued
• Head to Toe exam is next.
• Is the mental status diminished? It often is
with shock. Is there pallor from hemorrhage?
Look for neck vein distention – a reflection of
CVP and this may indicate tamponade,
cardiogenic shock and may clearly show that
hypovolemia is not the issue.
• Look at the belly. Is there any ecchymosis to
indicate trauma? Is there a pulsatile mass
from a AAA?
• Extremities:Pssive leg raise test transiently
increases venous return .Hypovolemia present
26. Shock
• Prehospital testing:
• A FS glucose may reveal marked
hyperglycemia
• EKG A STEMI is often the cause of cardiogenic
shock. Ischemia may also be the result of the
hypotension. Electrical alternans suggests
tamponade
27. Electrical Alternans
Electrical alternans is recognized by alternating
amplitudes of the QRS complexes. The most
frequent cause is a pericardial effusion . It is
thought to result from the swinging motion of
the heart from the weight of the effusion in the
perciardial sac.
![A recent NEJM study on the use of hypothermia
in children after cardiac arrests showed that
hypothermia resulted in a 30 % higher survival
[38 % vs 20 % survival] and a 70 % higher
likelihood of a good neurological outcome than
normothermia.
•Cooling slows metabolic demands , each
degree Celsius reduces the metabolic rate by 7
% . It will also decrease intracranial pressure and
decrease the heart rate.](data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7)