1

:6090180

6090180

4 - 6

--

(%)

5 %19 %26 %4 8

ACLS (min)CPR (min)

> 168 16< 8

10 %19 %43 %0 4

0 %6 %-8 12

2

VT Vf

pulseless arrhythmia irregular and chaotic electrical activity loses its ability to function as a pump. Sudden loss of cardiac output with subsequent tissue hypoperfusion creates global tissue ischemia;

VF is the primary cause of sudden cardiac death (SCD).

Irregular, choatic.* Loss of cardiac output. Pulse-less.

brain and myocardium are most susceptible.

Vf, pulseless VT

Primary ABCD. CPR. + defibrillation. (360J)Vf, VT : on endo, IV, monitoring. CPR. DDx.Bosmin 35 minutes/ 1 Amp IV. Vasopressin 40IU, .

VF or not

A

B

C

D

3

Oropharyngeal Airway

Nasopharyngeal Airway

The Oropharyngeal Airway

Nasopharyngeal Airway

1) 2) . Air hunger. 3) CO2 4) .

Laryngeal-Mask AirwayThe LMA was invented by Dr. Archie Brain at the London Hospital, Whitechapel in 1981The LMA consists of two parts: mask and tubeThe LMA has proven to be very effective in the management of airway crisis

4

Laryngeal-Mask Airway

The LMA design: Provides an oval seal around the laryngeal inlet once the LMA is inserted and the cuff inflated.

Once inserted, it lies at the crossroads of the digestive and respiratory tracts.

Defibrillation

Curved Blade Laryngoscope Inserted Against Epiglottis Visualization of Vocal Cords

Glotticopening

Arytenoidcartilage

Tongue

EpiglottisVallecula

Vocalcord

AnatomyAnatomy

Esophageal Tracheal COMBITUBE

Esophageal Tracheal Airway (Combitube), 140ml syringe, 20ml syringe, fluid deflector attachment

Insertion ProceduresPosition the patients neck in a neutral position.Lubricate the tube with sterile, water soluble lubricantLift the tongue and lower jaw upward to open the oropharynx

5

Insertion ProceduresAdvance tube until the patients teeth are between the two black lines

Esophageal PlacementIf the Combitube is placed in the esophagus, the distal balloon will occlude the esophagus.Ventilations are provided through perforations in the side of the pharyngeal tube.Stomach contents can be safely expelled via the hole in the end of the tube.

Tracheal PlacementIf placed in the trachea, it functions as an endotrachealtube, with the distal balloon preventing aspiration.Ventilations are provided via the hole in the end of the tube.Stomach contents can be safely expelled via perforations in the side of the pharyngeal tube.

Anaphylaxis

A severe allergic reaction that is rapid in onset and may cause death. [E (IgE), , histamine].(30)

Symptoms

Anaphylactic reactions almost always involve the skin or mucous membranes.

More than 90% of patients have some combination of urticaria, erythema, pruritus, or angioedema.

6

Symptoms--?

The upper respiratory tract commonly is involved, with complaints of nasal congestion, sneezingCough, hoarseness, or a sensation of tightness in the throat may presage significant airway obstruction.

Symptoms--,

Eyes may itch and tearing may be noted. Conjunctival injection may occur.

Dyspnea is present when patients have bronchospasm or upper airway edema.

Symptoms--

Hypoxia and hypotension may cause weakness, dizziness, or syncope. Chest pain may occur due to bronchospasm or myocardial ischemia (secondary to hypotension and hypoxia).

Airway patency

May be preferable to defer intubationattempts, and instead ventilate with a bag/valve/mask apparatus while awaiting medications to take effect. In extreme circumstances, cricothyrotomy or catheter jet ventilation may be lifesaving. Inhaled beta-agonists are used to counteract bronchospasm and should be administered to patients who are wheezing.

Bosmin, AntihistamineAdminister epinephrine to patients with systemic manifestations of anaphylaxis. With mild cutaneous reactions, an antihistaminealone may be sufficient, thus the potential adverse effects of epinephrine can be avoided. Patients on beta-blocker medications may not respond to epinephrine. In these cases, glucagonmay be useful. Antihistamines (eg, H1 blockers), such as diphenhydramine (Benadryl) are important and should be administered for all patients with anaphylaxis or generalized urticaria.

Steroid

Corticosteroids may not influence the acute course of the disease; therefore, they have a lower priority than epinephrine and antihistamines.

7

!!

Fast sugar testEyetoneFinger stick.

History taking ()

: DM history Hypoglycemia();

Coma cocktail

Coma cock tail50% G/W for hypoglycemic coma. Naloxone for Morphine intoxication. Thiamine for Wernickeencephalopathy.

Anexate (Flumazenil) for BZD overdose.

A,E,I,O,U,T,I,P,P,S

(1) Alcohol.(2) Epilepsy, Electrolyte imbalance. (3) Insulin-induced.- Hypoglycemia.(4) Opiate.5Uremia.6Trauma.7Infection.8 Poison.(TCA, BZD,.)9 psychi-()10Stroke, shock.chief complaint, present illness, history taking

asthma

, :

CAD/IHD, AMI, ACS)

(COPD, Asthma)(hyperventilation syndrome)

8

Asthma : etiology,

1., ..2...3.Cold air.4.5.6.

7. , . Allergy or -adrenergicPropranolol

Predisposing factor ,

mite

Wheezing 4(wheezing):

silent.

COPD nasal cannula 2 L/min.ACS (Acute coronary syndrome) nasal cannula 4L/min.Respiratory distress mask. Respiratory failure BVM, on endotrachealtube.

Hyperventilation syndrome

Make sure pulseoxymeter: well.Make sure normal breathing sound. history of emotional influence. Stress.Young, female. Occasionally elderly, male.Use plastic bag.

(ACS)

. (ACS).

:.

9

1.:,,, . 2..3.. 4.. 5.,,,,.

Call for help 119,,

,()NTG,,,,. AED ()12 lead ECG.

4()843

101710

Stroke

.7075%

2530%

?

Facial droop Arm Drift. Abnormal speech..Any 1 of 3, stroke rate: 72%.

Cincinnati Prehospital Stroke Scale.Acad Emerg Med. 1997;4:986-990

time is brain . ,oxygen, pulse oximetry.. K.V.O. ,

, , (aspiration).. If MAP > 130 mmHg. Head up 30 degrees.

10

Position ,

Head up 30 degrees. 30.

(tPA)

1). 18 y/o2). (Infraction) type.3). .

. tPAICH. , AVM, aneurysm, tumor.

, SBP> 185mmHg. DBP> 110mmHg.seizure attack.

< 10, 48 hoursheparin. INR >1.7 or PT> 15 sec wafrain

tPA

lumbar puncture, UGIB.

< 50 or > 400 mg/dL.

Victims from cardiac arrest are benefit from ECMO during CPR, when this arrest occurs from reversible conditions such as massive pulmonary embolism or CAD.

Acad Emerg Med 1999; 6:700707

The 2005 AHA guidelines for CPR and emergency cardiovascular care : ECMO during CPR should be considered for in-hospital cardiac arrest (IHCA) patients when the no-flow is brief and the condition is reversible(Class IIb)

Circulation 2005; 112(Suppl. I):IV-47IV-50

ECMO support can extend theduration of CPR

Review of consecutive adult in-hospital CPR patients without return of spontaneous circulation (ROSC) in 10 mins and with ECMO rescue, and analysis of the relationship between outcome and CRP duration and possible etiologies.

Patients: An observational cohort study in 135 consecutive adult in-hospital CPR patients without ROSC who received ECMO during CPR.

Crit Care Med 2008 Vol. 36, No. 9

11

Exclusion Criteria of ECPR. CPR with traumatic origin unless bleeding was under controlPrevious severe brain damageTerminal status of malignancyAn age 75 yrs.(80yrs)

The outcome of in-hospital CPR is quite varied and major studies have reported a survival-to-discharge of 10% to 20%.A large series of adult in-hospital CPR patients with only 18% survival had a median CPR duration of 18 mins in all patients combined, which was even shorter in survivors.

ECMO support can extend theduration of CRP

Main Results: The average CPR duration was 55.7 27.0 mins and 56.3% of patients received subsequent interventions to treat underlying etiologies.The successful weaning rate was 58.5%The survival-to-discharge rate was 34.1%. The majority of survivors (89%) had an acceptable neurologic status on discharge. Risk factors for hospital mortality included longer CPR duration, etiology of ACS, a higher organ dysfunction score in the first 24 hrs. Crit Care Med 2008 Vol. 36, No. 9

ECMO () 2002.12.1 2008

Bridge

(Myocarditis )

(Pulmonary embolism)

1. (Meconium aspiration syndrome) 2. (Hyaline membrane disease)3. (Congenital diaphragm hernia) 4. (Persistent pulmonary hypertension of

neonate)

5.

12

1. 2. 3. (Airway surgery)4. 5. (30)

Contraindications> 80 ()

ECMO

Trendelenburg's position

Head-down body tiltAnti-shock position

More likely to be effective during volume overloaded, not volume depletion.

13

()

14

15

16

17

-1

-2

18

24

18

-1

ECG /SpO2 monitorsET-CO2,BP monitor, defibrillator

-2

endo suction ET-CO2Hypoxia

-3

/ EndoCVP catheterA-linesChest tubesNGFoley

-4

Priority!!

CT scans

Emergent laparotomy, thoracotomy,pericardial window, craniotomy

19

-5

E.g. SpO2 BP PR GCS Prognosis

/

on-line medical direction

BLSALS

NG

(COPD)

()()():

Cardiac EnzymesBrain CT

Critical patients

20

SOP

Bypass

ABCDEs

benzodiazepines, fentanyl, propofol, ketamine,

Midazolam EtomidateThiopentalCitosol

Ketamine

21