Hersheychapter 1
Hersheychapter 1
Hersheychapter 1
Medicine
Cardiopulmonary Resuscitation
Advanced Life Support
Office Emergencies
Medical Emergencies (Cardiac Dysrhythmias)
Summary of CPR
Other Medical Emergencies
Shock
Blood and Blood Components for Emergency Use
EMERGENCY MEDICINE
Cardiopulmonary Resuscitation
1. Rescue breathing: Adult victim
a. Check responsiveness: shake or tap gently and ask "ARE YOU OK ?"
b. If unresponsive yell for help
c. Open the airway: head tilt/chin-lift to open airway, and check for
obstruction. Remove if present
d. Check for breathing: if no breathing then give 4 quick breaths (Observe
chest rise)
e. Check for pulse (Carotid) for 5-10 seconds: if .pulse is present but there is
no breathing then
f. Start rescue breathing: inflate @1 breath every 5 seconds. Continue for 1
minute
g. Reassessment: check pulse and breathing, if breathing then stop CPR. If
no breathing but pulse present, then just continue ventilations. If no
breathing and no pulse, then begin CPR
h. Start chest compressions over sternum: using heel of hand with
fingertips off sternum and with elbows straight; compress 181 /2 to 2
inches @ 80 to 100/ minute
i. Provide proper ventilations: give 2 breaths after 15 compressions if
working alone or 1 breath to every 5 compressions when two rescuers
are present
i. Atropine:
decreases vagal tone to increase heart rate
used in sinus bradycardia/high degree AV block
dosage- .5mg IV Q 15 minutes up to 2mg.
ii. Bretylium:
used in V-fibrillation and V-tach when lidocaine and countershock fails
dosage v-fib: 5-10gm/kg bolus Q 15 min to max 30mg/kg
dosage v-tach: 5-10 mg/kg IV over 10 minutes, then 1 to 2 mg/min IV drip
iii. Calcium:
should only be used to treat acute hyperkalemia, hypocalcemia, and
calcium channel blocker toxicity (there is no data showing its
effectiveness during CPR)
increases cardiac contractility and excitability
used in asystole
dosage: calcium chloride 2-4 mg/kg Q 10 minutes (Approx 500 mg)
used in pump failure
dosage: 2.5-1 Omicrograms/kg/min
iv. Dopamine:
alpha, beta, and delta agonist
used to support cardiac output, BP and renal perfusion in shock
states
dosage: start at 2-5 micrograms/kg/min, titrate to effect 20
micrograms/kg/min
large dose has mostly alpha effect
v. Epinephrine:
alpha and beta agonist, increases heart rate and contractility
used in asystole, V-fibrillation, and cardiac arrest
dosage: .5 to 1.0mg (5-10 ml of 1-10,000) IV Q 5 min
x. Propranolol (Inderal):
beta blocker (to be used with caution in patients with COPD, diabetes and heart
failure
used to control recurrent ventricular and atrial tachydysrhythmia
dosage: 1 mg IV Q 5 minutes to 5 mg total (total dose not to exceed 0.1 mg/kg)
must administer slowly
Office Emergencies
1. Syncope- Vasovagal reflex (Primary shock; fainting)
a. Defined as transient loss of consciousness due to sudden release of the
arterial vasomotor tone and temporary insufficiency of cerebral circulation
b. Causes are sudden extreme fear or pain or the effect of severe injury
c. Differential diagnosis: epilepsy, hyperventilation, hysteria , carotid sinus
syndrome, cardiac arrhythmia, drugs and orthostatic hypotension d. Signs
and symptoms: pallor, sweating, slow pulse, yawning and marked transient
hypotension
e. Treatment is supportive: recumbent position, take B.P., pulse, spirits of
ammonia, O2 and drugs (Atropine/Ephedrine) only if previous treatment fails
3. Anaphylactic Reactions
a. These are toxic reactions that occur in persons who are allergic by
heredity or who have become sensitized to a given drug or therapeutic
agent after previous administration. Respiratory obstruction is the
cause of death
b. Reactions- anaphylactic shock, angioneurotic edema (swelling of soft
tissues of throat), asthma with acute bronchospasm, urticaria and pruritus
c. Signs and symptoms of anaphylactic shock - skin wheals, itching,
angioedema, laryngeal edema, bronchospasm (wheezing) dyspnea,
cyanosis, apnea, vomiting, hypotension, cardiorespiratory collapse and
death
d. Treatment of anaphylactic shock (must be immediate)- .5cc epinephrine IV
or IM (children 0.01 mg/kg), tourniquet and .25cc epinephrine at injection site,
O2 & airway, Solu-cortef 200 mg IV and CPR if necessary
4. Allergic Reactions:
a. End organ response of the skin
b. Symptoms are hives, (urticaria), bronchial asthma, and G.I. upset c.
Treatment: 25-50 mg IM Benadryl- if severe then treat as if anaphylactic
reaction- if tongue swelling use epinephrine
7. Hypertension:
a. Defined as persistent elevated BP above normal for the patient
(borderline hypertension BP>140/90)
b. Signs and symptoms- headache, convulsions, visual changes, with acute
rise in BP
c. Treatment- start supportive therapy and reduce BP with sublingual
nifedipine 10mg (Procardia) then send for medical evaluation
NOTE* If the diabetic patient is seen when unconscious, and if the diagnosis of
coma or insulin reaction is in doubt, give 50% glucose IV- this will
overcome insulin reaction but will not generally harm patient in
diabetic acidosis
Medical Emergencies (Cardiac Dysrhythmias)
1. Myocardial Infarct (uncomplicated): Characterized on EKG by big Q waves
a. Monitor EKG
b.100% O2 with nasal cannula
c. Start IV lines with D5W
d. Sublingual nitroglycerin can help
e. Relieve pain with morphine sulfate
f. Do blood gases/pH/electrolytes
g. Consider use of prophylactic lidocaine
4. Ventricular Tachycardia:
a. Begin lidocaine
b. Use CPR if no pulse/O2/ IV's (and unconscious)
c. Use precordial thump if witnessed event
d. Consider cardioversion and procainamide or bretylium if lidocaine
ineffective
Wolff-Parkinson-White syndrome:
a. Characterized by a short P-R interval and prolonged QRS time. There is a
40% incidence of episodes of paroxysmal tachycardia, atrial fibrillation and
atrial flutter, as well as the possibility of sudden death. Can occur in healthy
individuals
b. Treatment: Digitalis, quinidine, propranolol, artrial pacing
4. Poisoning:
a. Each type of poisoning is treated differently a. Begin basic CPR if necessary
b. Determine ingested substance and give antidote if available
NOTE* It is better to call hotline first for specific directions in the treatment of
specific ingested agents
6. Hypertensive Emergencies:
Hypertensive encephalopathy
Malignant Hypertension
Accelerated Hypertension
Hypertensive Crisis
a. Diagnosis of Hypertensive encephalopathy or accelerated malignant
hypertension is a clinical one and demands immediate aggressive therapy
to lower BP
b. Treatment initially should be Diazoxide (Hyperstat) 300mg by rapid IV
bolus or can give hydralazine (should give Furosemide simultaneously-
prevents fluid retention)
2. Etiology:
a. Hypovolemic: Caused by a reduction in circulating blood as a result of
traumatic injury, GI bleed, crush injuries, burns, massive diarrhea, and
peritonitis
b. Septic: Caused by infections that produce an endotoxic or exotoxic
reaction. Most common gram (-)'s are E. coli, Proteus group, Pseudomonas,
Klebsiella and meningococci. Less often involved are gram (+)'s such as
staphylococci, streptococci, and clostridia
c. Neurogenic: Severe injury to the spinal cord or brain can cause a loss in
vasomotor tone resulting in vasodilation and hypotension from the loss of
peripheral vascular resistance. Also psychogenic factors such as the sight of
blood or surgery can produce shock
d. Cardiogenic: Produced by hypotension arising from inadequate cardiac
output as a result of serious arrhythmias, tamponade, Ml, CHF, and
pulmonary embolism
e. Metabolic: Caused by alterations in the fluid electrolyte balance as a
result of systemic diseases such as diabetic acidosis, renal failure, or chronic
respiratory diseases
f. Anaphylactic: Occurs following the injection of heterologous sera,
penicillin and other medications
3. Treatment of shock:
a. Assess the physical status of the patient
b. Lie the patient down and keep him/her warm
c. Maintain airway administering oxygen at 8-10 liters/minute. If patient
unable to breath on their own use Ambu bag (use- CPR if necessary)
d. IV fluid replacement to avoid dehydration. Do not use lactate solutions
NOTE* Expanding the intravascular volume is the primary goal in the initial
treatment of hypovolemic shock
NOTE* RBC's must be used within 4 hours after removal from the refrigerator
and must return within 20 minutes to the Blood Bank if not used. Warming
can result in bacterial proliferation if allowed to warm to room temperature
before returning to refrigeration
d. Adverse reactions:
i. Infectious reactions:
AIDS: Risk is 1:20,000 to 1:40,000 for each unit transfused
Hepatitis (B C): less than 1
MV
ii. Noninfectious reactions
Febrile: fever reaction most common. This reaction involving circulating
antibodies in the recipient which react to HLA antigens in infused
granulocytes
Allergic: associated with circulating serum antibodies within the
recipient to infused immunoglobulins within the small amount of residual
plasma of the red cell unit (hives, serum sickness, anaphylaxis)
Hemolytic: is a result of circulating naturally occurring antibodies in the
recipient to antigens on the RBC's causing cell lysis
Graft vs. host disease: engraftment and multiplication of donor blood cells
in an immunosuppressed recipient are possible, and here, immunocompetent
lymphocytes become engrafted and cannot be rejected
2. Platelets:
a. Description: Are a concentrate separated from a single donor by
plasmapheresis from whole blood containing 5.5 x 1011 platelets in 200
300 cc of plasma and anticoagulant, and can be expected to raise the adult
platelets count by 60-80,000 unless platelet antibodies are present
b. Compatibility: ABO compatibility is preferred, but in emergencies or short
supply any ABO group can be used (Rh is not a factor).
c. Alternatives: Random donor platelets are obtained from a single unit of
whole blood and contain 1 /10 the number of platelets in 30-50 cc, and 6-
10 units are standard suggested therapy
d. Indications:
L Prophylaxis:
Platelet count < 20,000/mm3 or anticipated drop below 20,000 in the
next 24 hours
Platelet count < 80,000 with surgery anticipated or in the acute post-op
period
A platelet function defect with surgery anticipated or in the acute post-op
period
i. Bleeding:
latelet count < 20,000/mm3
latelet function defect (known or suspected)
e. Adverse reactions: Same risks as RBC's
3. Cryoprecipitate:
a. Description: Prepared by thawing fresh frozen plasma at 4°C and
recovering the cold precipitate. Each bag of 'Cryo' contains 90 or more Factor
VIII units and at least 150 mg of fibrinogen in less than 15 ml of plasma
b. Compatibility: ABO compatibility is preferred but not required in
emergency situations
c. Alternatives: Fresh frozen plasma can be used if there are associated
deficiencies of individual coagulation factors, massive blood transfusion, or
when cryoprecipitate is in short supply
d. Indications:
i. Von Willebrand's Disease
ii. Hypofibrinogenemia associated with bleeding or surgery (perioperative)
iii. Dysfibrinogenemia associated with bleeding or surgery
iv. Uremia associated with bleeding
v. Factor XIII deficiency
e. Adverse reactions: Same as with RBC's