Download Coma

Back to Basics
2017
Dr. Brian Weitzman
Department of Emergency Medicine
Ottawa Hospital
Emergency Medicine Topics
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Syncope
Coma
Hypotension/Shock
Cardiac Arrest
Syncope
Syncope
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Syncope-MCC Objectives
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Definition
Distinguish from Seizure
Causes: serious or not, cardiac or not
List and interpret ‘Targeted’Hx, Px,
List and interpret investigations,
– ex cardiac: ECG, echo
• Initial Management Plan: meds,
• Who needs referral, fitness to drive
Syncope
• A 73 y.o. man collapsed in the bathroom and had a 30
second episode of unresponsiveness at 0430. He awakes
fully, and is brought to the Emergency Department by his
wife.
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Is this a syncopal episode?
What are the causes of syncope?
What is the likelihood he had a cardiac cause of syncope?
What is your workup and management of this patient?
What is syncope?
• Sudden, transient loss of consciousness
• Rapid and complete recovery
• May have minor myoclonic jerks or muscle
twitching
• No postictal state
How is a generalized seizure
different than a syncopal episode?
• SEIZURE
• Aura (parasthesia, noises, light, vertigo)
• Tonic-clonic movements and loss of
consciousness
• Post ictal confusion for minutes-hours
• Tongue biting
• Incontinence bowel or bladder
Syncope
• Prodrome often occurs
– Feeling faint, hot, lightheaded, weak, sweaty
• Brief loss of consciousness
– seconds to 1-2 minutes
• Rapid and complete recovery
• Speaking normally within 1 minute
– No post event confusion
What are the common causes of
syncope? (MCC)
• Cardiovascular (80%)
– Reflex/underfill (60%) (vasovagal, orthostatic)
– Cardiac arrhythmia (20%)
– Decreased cardiac output –MI, Aortic Stenosis
• Cerebrovascular (15%)
• Other
– Metabolic (low BS)
– Psychiatric
– Meds (anti-hypertensives)
Cardiovascular Causes of Syncope
• Reflex/Underfill (60% of syncope)
– Vasovagal (common faint)
– orthostatic/postural ex. Blood loss
– Situational (micturition, cough, defecation)
Cardiovascular Causes of Syncope
• Cardiac arrhythmia (20%)
– Tachy or bradycardia
– Carotid sinus syndrome
• Decreased cardiac output
– Inflow obstruction (to venous return) ex. PE
– Squeeze: Myocardial ischemia (decreased contractility)
– Outflow obstruction (Aortic stenosis, hypertrophic
cardiomyopathy
• Cerebrovascular Causes (15%)
– TIA
– vertibral basilar insufficiency
– high ICP
• Metabolic : hypoxia, low BS, drugs, alcohol
• Psychiatric: hyperventilation, panic
What is your initial approach with
your patient with syncope?
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Check ABCD,s,
6 vitals –postural, bedside glucose
monitor, IV, ECG, blood tests
Bolus fluids if hypotensive 250-1000cc NS
give thiamine if giving glucose
consider naloxone if patient not fully awake
history and physical
History
• what happened (witnesses important)
• what were you doing (ex. urination,
standing up quickly etc.)
• prodrome (hot, sweaty, vomiting)
• any tonic-clonic activity
• postural or neck turning
• recovery – long or short
– any confusion
Review of Systems
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volume status (eating, diarrhea, exercise)
recent blood loss
chest pain, palpitations, SOB,
any focal neurologic symptoms
pregnancy
PMH
• previous history of syncope
• ex. occasional episodes over the years vs
several episodes recently (more sinister)
• cardiac disease or medications
• bleeding disorders or PUD
• diabetes
• medications ex. antihypertensives often
cause orthostatic syncope
Physical Exam
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ABC
Orthostatic Vitals
HEENT: trauma, papilledema,
Resp/CVS: S3, AS murmur,
Abd: aorta, pulses, peritoneal, blood PR
Pelvic: bleeding, tenderness
Neurologic: focal findings
Lab Investigations
• CBC
• Type and xmatch
– If suspect acute blood loss AAA, ectopic, GI bleed
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Lytes, BS, BUN, Cr
D dimer
Pregnancy Test
ECG
CT Head if suspect cerebrovascular cause
Holter
EEG
Vasovagal Faint
• Common (60% all syncope)
• Increased parasympathetic tone
• Bradycardia, hypotension
Vasovagal Faint -Predisposing
Factors
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Fatigue
Hunger
Alcohol
Heat
Strong smells
Noxious stimuli
Medical conditions anemia, dehydration
Valsalva (trumpet player)
Vasovagal Faint
Symptoms and signs
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Warm, sweaty
Weak
Nausea
Confused
Unprotected fall
Eye rolling, myoclonic jerks,
Resolves in 1-2 min
Rarely tongue biting or incontinence
Not confused afterward
Cardiac Syncope
• 20% all syncope
• Serious prognosis
• Exertional syncope
– Outflow obstruction AS, IHSS
• Ischemia/MI
• Conduction disorders
• dysrhythmias
Orthostatic
• Decrease in systolic BP by 20-30 or
increase in pulse by 20-30 on standing
• Supine
• Meds -antihypertensives
• Blood loss, dehydration
Syncope-When to Admit
Canadian Syncope Risk Score
• History of heart disease
• ED diagnosis of cardiac syncope
• Predisposition to vasovagal symptoms
• ED diagnosis of vasovagal syncope
Canadian Syncope Risk Score
• Abnormal QRS axis
• QRS duration >130 msec
• QTc > 480
• Systolic BP <90 or >180
• Elevated troponin level
Syncope-When to Admit
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Uncertain diagnosis
Elderly (more likely cardiac)
Suspected cardiac etiology
Abrupt onset with no prodrome (typical for
dysrhythmia)
• Unstable vitals
• Blood loss
• Abnormal ECG
Our 73 y.o. man who collapsed in the
bathroom and had a 30 second episode of
unresponsiveness at 0430.
In the ED, he had another brief syncopal
episode, following by sinus tachycardia
What is his problem?
What would you do?
Our 73 y.o. man who collapsed in the
bathroom and had a 30 second episode of
unresponsiveness at 0430.
• Sick sinus syndrome: need pacer
An 80 y.o. man complains of recurrent
syncope
What is his diagnosis and treatment?
An 80 y.o. man complains of recurrent
syncope
What is his diagnosis and treatment?
• Third degree Heart Block
A 65 y.o. man on diuretics has
recurrent syncope
A 65 y.o. man on diuretics has
recurrent syncope
Long QT
Torsades de Pointes
Treatment of Torsades
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Correct electrolytes
Magnesium 2 gm over 20 min
Isoproterenol 2-20 mcg/min
Overdrive pacing
Cardiac Pacing
When is it required?
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3rd degree (complete HB)
2nd degree type ll
Sick sinus syndrome
Symptomatic bi or trifasicular blocks
– Ex. RBBB + LAH + 1st degree HB
• Symptomatic bradycardia
Fitness to Drive
• CPSO: > 16 yrs old
– Suffering from a condition that may make it
dangerous to operate a motor vehicle
• Single episode of syncope that is easily explained
ie. Simple faint dosen’t need reporting
• Recurrent episodes or suspected cardiac cause
– needs to be reported and the patient shouldn’t
drive til a cause is determined and treated.
Coma
Coma
MCC Objectives
• Definition
• Understand and Diagnose Causes of coma
– Vascular, infectious, trauma,
– metabolic, substance use/OD, seizures
• List and interpret key clinical findings:
– History, physical exam, differential diagnosis
– assessment tools (GCS)
MCC Objectives
• List and interpret critical investigations:
– Lab: tox screen, glucoscan, LP,
– DI: CT, MRI, EEG
• Initial management plan
– immediate treatment: A,B,C,D’s,
– Empiric RX: naloxone, flumazenil, glucose,
– Antibiotics, anticonvulsants
• Management of Incapacitated patients
– -proxy decision-making
What is Coma?
• MCC Defintion:
• state of pathologic unconsciousness
(unarousable)
An 80 y.o. man is comatose 2 weeks
after falling down stairs?
Why is this patient comatose?
Isodense Subdural Hematoma
Enhanced CT Head
A diabetic patient presence in a coma and is
found to have a BS of 1.5
Why are they in a coma?
Treatment ?
A diabetic patient presence in a coma and is
found to have a BS of 1.5
Why are they in a coma?
1 amp (50cc) D50W
contains how much sugar?
Coma
Can be induced by structural damage or chemical
depression
1) reticular activating system in brainstem, midbrain,
or diencephalon (thalamic area)
• Ex. Pressure from a mass
• Toxins
2) Bilateral cerebral cortices
– Ex. Toxins, hypoxia, hypoglycemia
A 45 y.o. ‘street’ person is brought
into the ED in a coma. What are the
causes?
Causes of Coma
• Structural
– Bleed, CVA, CNS infection,
• Metabolic (medical)
– A,E,I, O, U, TIPS
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A 45 y.o. ‘street’ person is brought
in to the ED in a coma. What are the
causes?
AEIOU TIPS
A - alcohol, anoxia
E – epilepsy, electrolytes (Na, Ca, Mg), encephalopathy (hepatic)
I - insulin (diabetes)
O - overdose
U - uremia, underdose (B12, thiamine)
T- trauma, toxins, temperature, thyroid
I - infection
P - psychiatric
S - stroke (cardiovascular)
What is your initial approach with
this comatose patient?
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A-airway protection (and c spine)
B-breathing O2 sat
C-6 vitals (pulse, BP, temp, BS)
D-dextrose Glucoscan
Thiamine (if giving glucose)
Naloxone (should have small pupils)
IV, ECG monitor, foley, labs
Hx, Px
Determine level of consciousness
Why Thiamine if giving a bolus of
glucose
• Precipitate Wernicke’s encephalopathy
• Cranial nerve palsy - ocular
• Confusion
• Ataxia
Level of Consciousness
• AVPU
– Awake, verbal, pain , unresponsive
• Glasgow Coma Scale
GCS
Best Eye Response. (4)
1. No eye opening.
2. Eye opening to pain.
3. Eye opening to verbal command.
4. Eyes open spontaneously.
Best Motor Response. (6)
1. No motor response.
2. Extension to pain.
3. Flexion to pain.
4. Withdrawal from pain.
5. Localizing pain.
6. Obeys Commands
Best Verbal Response. (5)
1. No verbal response
2. Incomprehensible sounds.
3. Inappropriate words.
4. Confused
5. Orientated
8 or less = coma
History
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What happened?
Symptoms: depression, headache
Gradual or sudden LOC
Sudden = intracranial hemorrhage
Gradual more likely metabolic, could be
subdural
• PMH: diabetes, thyroid, hypertension,
substance abuse, alcohol
• Meds,
Physical Exam
• Goal: Try and determine if a
structural lesion is present, or a
metabolic cause.
How do structural lesions present
differently than metabolic causes of
coma?
Physical Exam
• Structural lesions:
– Often have focal findings, abnormal pupils,
evidence of increased ICP
• Metabolic causes:
– No focal findings, pupils equal mid or small, no
evidence of increased ICP
Signs and Symptoms of
Increased ICP
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Headache, N, V,
Decreased LOC
Abnormal posturing
Abnormal respiratory pattern
Abnormal cranial nerve findings
Cushing Triad: late sign of high ICP
– high BP, bradycardia, and low RR = high ICP
Physical Exam
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Vitals
BP > 120 diastolic may cause encephalopathy
Hypotension uncommon with intracranial pathology
Temperature
– Infection, CNS or otherwise
– Neuroleptic malignant syndrome
• antipsychotics, dopaminergic (levadopa) , or
anti-dopamine (metoclopramide)
• Altered mental status, muscle rigidity, and fever
Respirations
• Cheyne stokes
– Fast alternating with slow breathing
• Brain lesions, acidosis
• Apneustic
– Pauses in inspiration
• Pons lesions, CNS infection, hypoxia
Physical Exam
• HEENT:
– Battle’s sign, hemotympanum.
– Breath odour
• Ex. Acetone = DKA
Pupils
• Metabolic:
– pupils usually react
• Structural:
– may be unilateral dilatation Why?
• Uncal herniation presses on CN 111,
• Lose Parasympathetic tone
• Unapposed sympathetic stimulation
• 10% normal people have 1-2 mm difference
Pupils
• Fixed dilated pupils ominous
• Dead, central herniation, hypoxic injury
• Small pinpoint pupils
– Lesion in pons (ischemic or bleed
– Opiate OD
Physical Exam
• Corneal Reflex
– Sensory CN 5, and Blink is CN 7
Extraocular Movements
• Helps determine brainstem function in coma
• Doll’s eyes
– Eyes move in opposite direction to head
movement
– indicates functioning brainstem
Oculocephalic Reflex
Ensure C spine cleared
• Awake person:
– eyes look forward, some nystagmus
– Requires intact vestibular system and cortex
• Comatose patient with brainstem function:
Eyes deviate completely in opposite
direction to head movement
• Comatose Patient with no brainstem function
– Eyes follow head movement
Oculovestibular Reflex
Cold Calorics
• Check eardrum
• 50 cc iced saline
• Awake person:
– COWS
– Nytagmus away from cold
– Driving a car, cerebral cortex keeps you on the
road
Oculovestibular Reflex
Cold Calorics
• Comatose patient, intact brainstem
– Eyes deviate to cold side
– Hey who’s putting ice in my ear
• Comatose patient, nonfunctioning brainstem
– No reaction
Physical Exam cont.
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Disc
Nuchal rigidity
Resp/CVS/Abd/Extrem
Neuro:
level of consciousness, CN, Motor, Sensory,
DTR
Motor Exam
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Is there asymmetry in response to pain
Evidence for seizures?
Withdrawing: nearly awake pt
Decorticate:
– Abnormal flexion response. Flexes elbow,
wrist, and adducts shoulder
– Cerebral cortex injury
Motor Exam
• Decerebrate posture
– Extends elbow with internal rotation
– Lesions or metabolic effect in midbrain
• Flaccidity
– Ominous sign
– Toxin/OD
Labs ?
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CBC,
Lytes, Bun Cr, BS
LFT, Ca, Mg,
ABG
Alcohol, Osmolality
Tox screen
CO level
Diagnostic Tests/Imaging
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CXR
CT Head
LP
ECG
EEG
A 25 y.o. woman presents in a coma.
Pupils pinpoint. RR 8. No focal
findings?
What will you do?
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ABC’s, vitals
BS
Naloxone 0.4-2 mg IV
What if she is chronically taking narcotics?
A 30 y.o. man, hit on the head,
comatose with a unilateral fixed
dilated pupil?
What would you do?
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Intubate, pC02 to 30 mmHg
Elevate head 30 deg
Mannitol .5 gm/kg
CT Head
Stat Neurosurgery consult
Uncal Herniation
Substitute Decision Maker
• Who can be a substitute decision maker in a
patient who is incapacitated or unable to
decide for themselves?
• Who has the higher authority:
– Spouse
– Sibling
– Parent
Substitute Decision Making
Highest of
Summary COMA
• ABC, Vitals, BS, 02, CO2, Naloxone
• Metabolic vs Structural
• Key to Exam
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Respiration
Pupils
EOM
Motor response
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Hypotension Shock – MCC Objectives
• Causes
• List and interpret critical findings
– Symptoms and signs of shock
– Diagnose cause and urgency
• List and interpret critical investigations
– Tests to confirm presence and cause
• Management strategy
– Restore tissue perfusion
– Specific therapy related to cause
What Is Shock
• Tissue hypoperfusion or tissue hypoxia
Shock
• Catecholamine surge
• Vasoconstriction, increased cardiac output
• Renin-angiotensin, vasopressin
– Salt and water retention
Shock
• If persists
– Lactic acidois, decreased cardiac output, and
vasodilation
– Cell membrane ion dysfunction,
– cell edema
– Leakage of cellular contents
– Cell and organ death
Shock What are the causes?
• Pump
• Fluid
• Pipes
Card
iac
Shock What are the causes?
Obstructive
Obstructive
Card
iac
Hypovolemic
Distributive
Decreased Cardiac Output
• Obstructive Shock
– PE, Pulmonary hypertension
– Pericardial tamponade
– tension pneumothorax
Decreased Cardiac Output
• Intrinsic Dysfunction: Pump Failure
– Myopathy (ex ischemia)
– Mechanical (ex valvular)
– Dysrhythmia
Hypovolemia
– Blood Loss
• Trauma, AAA, aneurysm, GI bleed, ectopic
– Dehydration
• Gastro, DKA, Burns
Distributive
• Decreased systemic vascular resistance
• SANTA
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Sepsis –most common
Anaphylaxis
Neurogenic
Toxic (cyanide), CO, acidosis
Adrenal: addisonian crisis
Initial Management
• ABC’s
• Vitals
• MAP = DBP + 1/3 PP (SBP-DBP)
– MAP <70 = shock (inadequate perfusion)
• IV How much?
– Fill the patient up
• Two, 16 ga, 500-1000cc bolus
• Cardiac shock: bolus 250 cc at a time
Hx and Px
• Ask questions and examine carefully to rule
in or out all of the major causes of shock
• ABC approach
• Head to Toe Survey
Labs
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BS
CBC, lytes, liver/renal function
Lipase, fibrinogen, fibrin split products,
Cardiac enzymes, ABG/VBG, ECG, urine,
Tox screen
Stool OB
A 75 y.o. comes in confused x 2
days, lethargic
• BP 80/50 P. 130 T 38 RR 25 02 85%
• What is his diagnosis?
• What would you do?
Septic Shock
• Fluids: normal saline 1-2 litres
• Oxygen
• Treat the infection:
– Find the source
– Antibiotics: broad spectrum
• 3rd generation cephalosporins
• Pip-tazo
• BP support: inotropes: dopamine
A 39 y.o. man arrives in the ED having been
stung by a bee 30 minutes ago. He has hives,
facial and tongue swelling and is dyspneic.
• What will you do?
• BP 70/50 P. 140
Anaphylaxis
• 100 % oxygen
• bolus 1-2 litres normal saline
• epinephrine 0.3 mg IM q5min (repeat q 5 min prn)
• or 5-15 microgm/min IV with shock
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benadryl 50 mg IV
ranitidine 50 mg IV
solumedrol 125 mg IV
Glucagon 1mg IV if on beta blockers
Shock
Obstructive
Obstructive
Card
iac
Hypovolemic
Distributive
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Cardiac Arrest – MCC Objectives
• Causes
– Cardiac and noncardiac
• List and interpret critical clinical findings
– Pulseless state
– Determine etiology
• List and interpret critical investigation
• Management plan-CPR and ACLS protocols
• Communicate with families
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Outcome
Breaking bad news
Organ donation
Autopsy request
Cardiac Arrest - Causes
• Cardiac
– Coronary artery
– Conduction
• Metabolic: hypo Ca, Mg, K, anorexia
• Dysrhythmia: brady or tachy
– Myocardium
• Hereditary: cardiomyopathy
• Acquired: LVH, Valve disease, myocarditis
Cardiac Arrest - Causes
• Non Cardiac
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Tamponade
PE
Tension
Trauma
A 72 y.o. man complains of chest
pain and collapses in the ED
• What are you going to do ?
Sudden Cardiac Arrest
• electrical accident due to ischemia or
reperfusion
• 80%
ventricular fibrillation or
ventricular tachycardia
• 20 %
asystole
pulseless electrical activity
Mechanism of Fibrillation
• ischemia:
slows conduction
• adjacent myocardium in various phases of
excitation and recovery
• multiple depolarizing reentrant wave fronts
Ventricular Fibrillation (V. fib.)
Ventricular Tachycardia (V. tach)
Cardiac Arrest
• What are the key actions that are required to
improve survival from cardiac arrest?
2015 Chain of Survival
High Quality C.P.R.
• Compression : Ventilation ratio (30 : 2)
– Until advanced airway
• Minimize interruptions in CPR
– > 60-80% compression fraction
• Push Hard & Fast : 2-2.4 inches (5-6 cm)
• / 100-120/ min.
• Full chest recoil-lift hands off chest
• Change compressors q2min
Airway Management
• BVM (Bag-Valve-Mask)
– Avoid hyperventilation!
– 10 breaths / min. interposed with CPR
• Secure Airway & Confirm Placement
– No need to pause compressions!
• Advanced airway: LMA, ETT
– Ventilate q6 seconds
– ETCO2 monitoring !
A patient you are talking to suddenly
becomes unresponsive
The crash cart arrives, you grab the paddles
and have a quick-look
Is this
A) Normal sinus rhythm
B) Ventricular tachycardia
C) Ventricular fibrillation
D) Can I call a friend?
Would you:
A) Do 2 minutes of CPR then defibrillate
B) Defibrillate immediately
CPR Guidelines
• Once V fib (or any shockable rhythm) is
recognized…shock ASAP
• Minimize perishock pause
If you can’t get an IV, what other
route can you give drugs?
• Intraosseus
• Endotrachael: (not a good route)
Intraosseous Access
Your patient is still in this
rhythm !
Cardiac Arrest Medications
Only a few changes in 2015 Guidelines
• Vasopressors
– Epinephrine
• 1 mg q3-5 min
– Vasopressin
X
• No longer recommended
Cardiac Arrest Medications
• Antiarrythmics
• Don’t revert v fib.
• Work by preventing V.Fib,
– Amiodarone –
– Lidocaine
– Magnesium Sulfate
• (only for long QT or torsades)
Amiodarone
• First line antidysrhymthmic
• 300 mg IV bolus
• May give 2nd dose: 150 mg
Lidocaine
• 1.5 mg/kg
• Repeat x 1 prn.
ECPR
Post Arrest Care
• The paramedics brings in a 56 y.o. man who
arrested at home, was successfully
defibrillated but remains comatose and
intubated. BP. 100/70, P. 75 NSR
• What other treatment options are available
to you to increase survival?
Post Arrest Care
1. Consider reperfusion in Cath Lab
– STEMI
– Hemodynamic or electrical instability
2. Targeted Temperature Management
TTM Targeted Temperature Management
Cardiac Arrest
• Cool to 32-36°C x 24 hrs
• Criteria:
– adult patient prehospital cardiac (v.fib) arrest
– Spontaneous circulation BP > 90
– Patient remains comatose and intubated
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A 69 y.o. patient you are assessing
for chest pain suddenly complains of
palpitations
Is this
A) Normal sinus rhythm
B) Ventricular tachycardia
C) Supraventricular tachycardia
D) I don’t know but it looks bad
A 69 y.o. patient you are assessing
for chest pain suddenly complains of
palpitations
Is this
A) Normal sinus rhythm
B) Ventricular tachycardia
C) Supraventricular tachycardia
D) I don’t know but it looks bad
Pulse is present. What do you do next?
1) Cardiovert
2) Defibrillate
3) Amiodarone 150 mg IV
4) Lidocaine 100 mg IV
5) Need more information
What do you do next?
Determine if patient stable or unstable!
BP 110/60, no SOB, no chest pain
A) lidocaine 100 mg
B) amiodarone 150 mg IV
C) sedate and cardiovert
D) adenosine 6 mg IV
E) metoprolol 5 mg IV
Which medications are useful for
terminating monomorphic VT
• Lidocaine: 6 studies (8-30% effective)
• Procainamide: few studies
– 30% effective
• Amiodarone: small case reports only
• 30%
Amiodarone in V. Tach
• 150 mg over 10 min
• may repeat up to 5-7mg/kg
• infusion: 1 mg/min for 1st 6 hours
»then 0.5 mg/min
Procainamide in V. Tach
• 17mg/kg max dose at 20-50 mg/min
• Stop infusion if:
– VT reverts to NSR
– Hypotension
– QRS widens
Ventricular Tachycardia
• Do not give multiple antidysrhythmics if
one has failed (pro-arrhythmic effects)
• pick one antidysrhythmic, if it fails, go to
electrical cardioversion.
Ventricular Tachycardia-Summary
• If stable: can try drugs but cardioversion best
choice
• If unstable: cardiovert (synchronized)
• If pulseless: defibrillate
An 80 y.o. patient admitted for
pneumonia is found unresponsive
by a medical student
• What is your management
• This is his rhythm on the monitor!!
Asystole
Witnessed Arrest ?
Yes
CPR - Intubate - IV access
Confirmation in 2 leads
No
ACLS futile?
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Possible causes
Hypoxia
Thrombosis, PE or MI
Hyper/hypo K
Toxins
H ion
Tamponade
Hypovolemia
Tension Pneumothorax
Hypothermia
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Epinephrine 1 mg IV q 3 - 5 min
Consider termination of efforts
A 65 y.o. man admitted to the CCU with
chest pain is found unresponsive by the
medical student. He has no pulse.
He has the following rhythm
PEA
• Treatment:
• Find and treat cause
– Is there a shockable rhythm?
– Is this a paceable rhythm?
• Epinephrine 1 mg IV
PEA
• Consider causes:
– 5 H’s :
– hypovolemia, hypoxia, H ion, hyper/hypo K,
– Hypothermia
– 5 T’s:
– tamponade, tension pneumo, thrombosiscoronary or pulmonary, toxins
A 49 y.o. patient arrives in the ED complaining of
palpitations for 1 hour.
Pulse 185
What is this?
A) Atrial fibrillation
B) Atrial flutter
C) Ventricular tachycardia
D) A-V nodal re-entrant tachycardia
E) Sinus tachycardia
What will you do?
SVT
STABLE
UNSTABLE
CARDIOVERSION
VAGAL MANOEUVRES
Class 1
Verapamil 2.5 – 5 MG I.V. over 2 min or Diltiazem 20 mg IV over 2 min)
or
Adenosine 6 mg IV then 12 mg if needed
RAPID PUSH
or
Metoprolol 5 mg IV repeat x 2 prn
A 55 y.o. man develops palpitations
No chest pain, or SOB. BP. 150/85
A 55 y.o. man develops palpitations
A) MAT
B) A. fib.
C) A. flutter
D) SVT
E) Sinus arrythmia
What is your initial management?
A) Rate control
B) Rhythm control
C) Consider long term anticoagulation
Atrial Fibrillation
• How are you going to rate control ?
A) Metoprolol 5 mg IV
B) Verapamil 5 mg IV
C) Diltiazem 20 mg IV
Medications useful for pharmacologic
cardioversion
•
•
•
•
•
Procainamide 20mg per minute to 17 mg/kg
Propafenone 600 mg PO
Amiodarone 5 mg/kg
Ibutilide 1 mg IV
Magnesium 2 gm IV
What if the duration of the atrial
fibrillation was unknown or > 48
hours?
Risk of Stroke
• 5 % if cardiovert > 48 hours with no coumadin
• 0.8% risk of CVA with coumadin x 3 weeks
How Do You Determine Long
Term Risk of Stroke
• CHADS 65 : CCS Update on A fib
– Can J of Cardiology 2014
– Score 1 or > = oral anticoagulant
•
•
•
•
•
CHF
Hypertension
Age > 65
Diabetes
Previous stroke or TIA
What is the Rhythm and Rx?
Atrial Flutter
Clues: rate approx 150, saw-tooth pattern in inf. leads
usually requires cardioversion if < 48 hrs
-medications do not cardiovert this rhythm
-same anticoagulation considerations with a fib.
A 75 year old woman complains of dizziness.
A) NSR
B) Second degree HB type 1
C) Second degree HB type 2
D) Third degree HB
What are the treatment options if:
1) her BP is 120/80 and she looks well
2) her pulse was 45, BP 70/30 and she looks ill
A 75 year old woman complains of dizziness.
A) NSR
B) Second degree HB type 1
C) Second degree HB type 2
D) Third degree HB
What are the treatment options if:
1) her BP is 120/80 and she looks well
2) her pulse was 45, BP 70/30 and she looks ill
Second degree HB type ll
• Dysfunctional His Purkinje system
can lead to complete heart block
• If stable, send to monitored bed, and
arrange permanent transvenous pacer
• If unstable: external pacing, or dopamine or
epinephrine infusion.
A 70 yo woman complains of dizziness x 3 days
What is this rhythm?
A) NSR
B) Second degree HB type 1
C) Second degree HB type 2
D) Third degree HB
A 70 yo woman complains of dizziness x 3 days
What is this rhythm?
A) NSR
B) Second degree HB type 1
C) Second degree HB type 2
D) Third degree HB
Would 1 mg of epinephrine be
appropriate if her BP was 60/40
A) Agree
B) Disagree
Second Degree Type 11 and
Third Degree Heart Block
• Permenent pacing required
• If symptomatic:
– dopamine 5-20 microgm/kg/min OR
– epinephrine 2-10 microgm/min OR
– transcutaneous pacemaker
– Atropine not effective
A 55 y.o. man with nausea and vomiting
What is the rhythm and treatment?
A) NSR
B) Second degree HB type 1
C) Second degree HB type 2
D) Third degree HB
A 55 y.o. man with nausea and vomiting
What is the rhythm and treatment?
A) NSR
B) Second degree HB type 1
C) Second degree HB type 2
D) Third degree HB
Second degree HB type 1
• Check vitals, treat cause, (diphenhydramine,
ntg for chest pain)
• Atropine 0.5 mg if persistently hypotensive
– Max total 3 mg atropine
– Pacing and epi or dopamine infusions rarely
required
Bradycardia
When to Treat ?
• Symptomatic: chest pain, SOB, hypotension
• Therapy:
–
–
–
–
atropine 0.5-1 mg (max total 3 mg)
dopamine 5-20 microgm/kg/min OR
epinephrine 2-10 microgm/min OR
transcutaneous pacemaker
A 72 year old man complains of
persistant retrosternal chest
heaviness
What is your management ?
Is this: A) Pericarditis
B) Benign Early Repolerization
C) STEMI
A) Agree
B) Disagree
Is this: A) Pericarditis
B) Benign Early Repolerization
C) STEMI
A) Agree
B) Disagree
Myocardial Infarction
What can you do?
• MONA
–
–
–
–
ASA 160 mg chew
Oxygen (if sat < 95%)
nitrates sublingual or IV
morphine 2-3 mg prn
Myocardial Infarction
What can you do?
•
•
•
•
Antiplatelets: clopidogrel or ticagrelor
Heparin
Thrombolytics < 30 mins
Primary PTCA <90 mins
– Percutaneous transluminal coronary angioplasty
An 80 year old man is being
treated in hospital for pneumonia.
He is found VSA at 0300. His
rhythm shows asystole.
How long are you required to
perform CPR for?
CPR and ACLS
Purpose: treatment of sudden
unexpected death.
When Not To Initiate CPR
• CPR is inappropriate and ineffective for
medical problems where death is neither
sudden or unexpected
• don’t offer CPR as an option to patients or
families if it is not medically indicated
• communicate openly
When to Discontinue CPR
• Judgement that patient is unresuscitatable
• Variables:
– down time, rhythm, age, premorbid conditions
– advance directives
Summary
• Causes of Cardiac Arrest
• Team Efficacy
• Optimize compression fraction
• VF/ Pulseless VT
• PEA/Asystole
• Tachycardias
– VT, SVT, A Fib, A flutter,
• Bradycardias and blocks
?