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
