CARDIO-PULMONARY ARREST Tamponade

Last post was slightly outdated. I reviewed the new Difficult to diagnose during CPA
AHA Guidelines and made revisions to this handout. Usual sign: distended neck veins & hPN; absent
Please see new post on AHA ACLS UPDATE. Thanks. during CPA
Suspect if w/ a hx of chest trauma
REVERSIBLE CAUSES OF CPA (4H, 4T) Tx: needle pericardiocentesis (done by expert)
- Potential causes or aggravating factors for cardiac
arrest w/ specific treatments Toxic Substances
Common toxins & antidotes:
4 Hs: Paracetamol - N-acetylcysteine
Hypoxia Digoxin - Digoxin-specific FAB
1. Ensure adequate ventilation w/ 100% O2 antibodies
2. Ensure adequate chest rise Benzodiazepines - Flumazenil
3. Listen for bilateral breath sounds Opioids - Naloxone
4. Ensure correct positioning of tracheal tube (if IT) Tricyclics - Sodium bicarbonate IV
Beta blockers - Glucagon
Hypovolemia
1. Expose pt; look for signs of bleeding/fluid loss Thromboembolism
2. Gain multiple IV access Tx: thrombolysis
3. Restore intravascular volume w/ IVF FD; give
whatever fluid is available General Rules When Breaking Bad News:
4. Refer STAT to surgeons if CO is returned 1. Ensure you have somewhere quiet, private & free
from interruptions to talk to relatives
Hyperkalemia 2. Confirm that you are talking to the correct
1. There is no point in obtaining venous samples relatives
during CPA 3. Always sit at the same height as the relatives
2. Ascertain most recent test results 4. Do not give impression you are busy or in a hurry
3. Look for peaked T waves in recent ECG 5. Use “dead” or “died”. Do not leave room for doubt
4. Look at drug chart for meds that may cause 6. Don’t be afraid of long pauses.
metabolic disturbances or any hx that could be 7. Touching may be appropriate
suspect for metabolic disturbance 8. Be prepared for a variety of reactions
5. Calcium Chloride IV for hyperK, hypoCa, Ca- 9. Ask relatives if they have any questions
channel blocker overdose 10. Know local policies for collecting belongings,
death certificates & death registration
Hypothermia 11. Allow relatives to view their loved ones
- Core body temp <35º C
Mild – 35-32º C Family Presence During Resuscitation:
Moderate – 32-30º C 1. Accommodate family member’s wish to be present
Severe - <30º C during resuscitation; lack of space & team leader
1. ALWAYS CHECK FOR PULSE & RR FOR 1 MINUTE reluctance are NOT reasons for refusal
IF PT IS HYPOTHERMIC! 2. Do not make them feel as if they are in the way or
2. Movement precipitates arrhythmia intruding
3. Chest stiffness makes ventilation & compressions 3. Explain what they have to expect in the area &
difficult that it is their choice to stay or go
4. Delay defib until T>30º C 4. Accompanying RN:
5. Resuscitation may be prolonged (The pt isn’t dead a. Must remain w/ relative at all times
until they are warm and dead!) b. Must not be involved in the resuscitation
6. Slowly re-warm using warmed fluids attempt
7. Consider gastric & bladder lavage w/ warmed c. Must ensure safety of relative at all times
fluids especially during defib
d. Allow to stand close to loved one but in a
4 Ts position where they will not interrupt the
Tension Pneumothorax resuscitation effort
Features: e. Must go w/ relative if they wish to leave or
a. Diminished breath sounds on affected side if they disrupt the attempt; bring them to a
b. Hyperresonance on affected side quiet, private place to wait
c. Tracheal deviation to the contralateral side 5. TL must explain decision to stop the resuscitation
Emergency Tx: 6. Allow time to be w/ their loved one
1. Insert large bore cannula into 2nd ICS MCL on 7. Allow opportunity to ask questions
affected side
2. If successful, you will hear a hiss of air
3. Insert chest drain after successful CPR
ACUTE POISONING AND DRUG OVERDOSE IMMEDIATE MANAGEMENT
Poisoning 1. ABCDE
- Chemical injury to organs of the body 2. If â LOC – insert FBC
- Chemically induced disturbance of the function 3. NSS if hPN
of the body’s systems 4. Identify poison; if unsure, get help
5. Gastric lavage – if airway is protected or w/
S/Sx: ingestion of life-threatening amount of drug or
CNS acting drug – depressed respiratory drive toxic substance w/in last hour; avoid w/ corrosive
Barbiturates/Tricyclics – skin blisters substance
Barbiturate OD – hypothermia 6. Give antidote & monitor its effect
Opioid OD – needle marks in arms, pinpoint pupils 7. Explain, gain consent, ask what they want their
relatives to be told/not told
Management 8. Psych evaluation during discharge
Airway
1. Ensure patent airway INHALED POISONS (CARBON MONOXIDE
2. Nurse in recovery position if unconscious POISONING)
3. Use guedel airway or nasopharyngeal airway PRN CO – binds to circulating hemoglobin
4. Intubate if unable to maintain airway (carboxyhemoglobin) thus reducing oxygen-carrying
5. Prevent aspiration (á risk following OD) capacity of blood
Causes:
Breathing - Industrial or household incidents
1. High flow O2 if unconscious – except in paraquat - Attempted suicide
poisoning
2. Monitor O2 sat and RR S/Sx:
3. Bag valve mask PRN in ventilation Predominantly CNS symptoms:
4. RR <12 CPM – 800 mcg-2 mg IV to a max of 10 1. Cerebral hypoxia – may appear intoxicated
mg q 2 mins until RR; further doses may be 2. Psychosis, spastic paralysis, ataxia, visual
required disturbances
3. Headache
Circulation 4. Mm weakness
1. Gain IV access 5. Palpitation
2. Cardiac monitoring 6. Dizziness
3. ECG recording 7. Confusion rapidly progressing to coma
4. BP Monitoring q 30 mins 8. Pink or cherry red/ cyanotic/ pale skin color –
5. If hPN, give NSS IV not reliable!
6. If hPN that doesn’t respond to IV, consider central
line Goals of Management:
7. Summon medical assistance 1. Reverse cerebral & myocardial hypoxia
2. Hasten elimination of CO
Disability
1. Assess using AVPU or GCS Management:
1. Carry pt to fresh air STAT; open all doors &
Exposure windows
1. Look for needle marks, skin blisters, empty packs, 2. Loosen tight clothing
undigested tablets 3. Initiate CPR if required; administer O2
4. Prevent chilling; wrap in blankets
LIFE THREATENING FEATURES 5. Keep pt as quiet as possible
1. Coma – not opening eyes, not obeying 6. Do not give alcohol in any form
commands, not uttering understandable words :
assess GCS
2. Cyanosis – clinical observation: assess for In the ER:
peripheral & central cyanosis 1. Carboxyhemoglobin analysis
3. Hypotension – NSS IV; consider central line 2. 100% O2 – reverse hypoxia & accelerate
4. Paralytic ileus – functional obstruction due to elimination of CO; given until level is <5%
reduced bowel motility: listen for BS 3. Psych consultation once stable if poisoning
was a suicide attempt
IMMEDIATE INVESTIGATIONS
1. Obtain venous blood – U&E, paracetamol levels, INJECTED POISONS (STINGING INSECTS)
LFTs, INR - Extreme sensitivity to venoms of the
2. Obtain ABGs Hymenoptera (bees, hornets, wasps, fire ants)
3. Save blood & urine samples for further toxicology - Venom allergy – IgE-mediated reaction
screens
4. Obtain ECG & CXR
S/Sx:
1. Generalized urticaria BREATHING
2. Itching 1. Assess O2 sat; maintain at > 92%
3. Malaise 2. High flow O2 via non re-breath mask
4. Anxiety 3. Assess RR
5. Laryngeal edema, severe bronchospasm, 4. Examine respi system
shock, death 5. Request CXR
CIRCULATION
Management: 1. Ask for medical help!
1. Stinger removal 2. Assess HR & rhythm
2. Wound care w/ soap & H2O 3. Record BP – hPN is a poor prognostic sign
3. Avoid scratching 4. Gain IV access
4. Ice application 5. Obtain venous blood for U&E, CBC and CHO
5. Oral antihistamine & analgesic 6. Obtain ABG
6. Anaphylaxis – Epinephrine SQ; massage site to 7. Monitor BG using capillary sample
hasten absorption 8. Obtain ECG
7. Desensitization 9. Insert FBC, monitor UO qH if unconscious or if no
8. Pt and family education UO w/in 3 hrs of starting IVF
10. Record temp
SNAKE BITES 11. Obtain midstream urine before starting antibiotics
Snake venom – consists of proteins w/ a broad range 12. If febrile, obtain blood culture & start broad-
of physiologic effects (neurologic, cardiovascular, spectrum antibiotic in accordance w/ local policies
respiratory) 13. Test for ketonuria
14. Give IVF NSS over 30 mins; then over 1 hr, then
Management: over 2 hrs, and then over 4 hrs
1. Let victim lie down 15. KCl if hypokalemic; monitor HR
2. Remove constrictive items such as rings 16. Insulin infusion – 1 “U”/ml in NSS via syringe
3. Provide warmth pump; run at 6 “U”/hr
4. Cleanse the wound 17. Monitor BM hourly
5. Cover wound w/ light sterile dressing 18. Once BM < 15 mmols/l, reduce insulin infusion to
6. Immobilize injured area below level of heart 3 “U”/hr and change IV to D5W
7. DO NOT APPLY ICE OR TOURNIQUET! 19. Monitor serum K every time IVF is changed
8. No corticosteroids for the 1st 6-8 hours 20. If BM < 6 mmols/l, reduce infusion to 1 “U/hr
9. Antivenin w/in 1st 12 hours; IVF for hPN 21. Rpt ABG
22. If still acidotic & DHN, give NSS w/ D5W over 8
DIABETIC KETOACIDOSIS (DKA) hrs
- Grossly deficient insulin availability causing 23. Don’t give NaHCO3; can be given by an ICU
transition from glucose to lipid oxidation & specialist
metabolism
DISABILITY
CAUSES: 1. Assess LOC using AVPU
1. Lapse in insulin tx 2. Coma – refer to ICU
2. Acute infection, trauma, infarction 3. â LOC – cerebral edema; refer to ICU

S/Sx: EXPOSURE
1. Thirst 1. Complete hx and PA once stable
2. Polyuria 2. Search cause for DKA once stable
3. Flushed appearance
4. Kussmaul breathing (sighing respirations) HYPEROSMOLAR NON-KETOTIC SYNDROME
5. Smell of ketones in breath (HONK)
6. DHN - Severe hyperglycemia w/o ketosis
7. Drowsiness - Clinical emergency in DM 2 pts

LIFE THREATENING FEATURES S/Sx:

1. Coma 1. Thirst
2. Severe acidosis – pH < 6.8 2. Polyuria
3. Severe hypotension unresponsive to IVF 3. Flushed appearance
4. Kussmaul breathing
Management 5. Smell of ketones in breath
AIRWAY 6. DHN
1. Assess & maintain airway 7. Drowsiness
2. Use head tilt/ chin lift PRN 8. Seizures
3. Use airway adjuncts if required
4. Refer to anesthetist for intubation
AIRWAY 7. Diaphoresis
1. Assess & maintain airway 8. Altered sensorium
2. Head tilt/ chin lift PRN 9. Oliguria – LATE!
3. Airway adjuncts if required 10. Metabolic acidosis
4. Refer to anesthetist for intubation 11. Hyperpnea

BREATHING GOALS OF EMERGENCY MANAGEMENT:

1. Assess O2 sat; maintain > 92% 1. Control bleeding
2. High flow O2 via non re-breath mask 2. Maintain adequately circulating blood volume for
3. Assess RR tissue oxygenation
4. Examine respi system 3. Prevent shock
5. Request CXR
MANAGEMENT:
CIRCULATION 1. Fluid Replacement
1. Get medical help! - Maintain circulation
2. Assess HR, BP - 2 large bore IV cannula
3. Gain IV access - Isotonic, colloid & blood component therapy
4. Obtain venous blood for U&E, CBC, CHO - PRBC – for massive blood loss
5. Obtain ABG – absence of ketoacidosis - Not enough time for typing & cross-matching
6. Monitor BG using capillary sample - “O-” – women of childbearing age; safest w/o
7. Obtain ECG sensitizing an Rh-negative woman
8. Insert FBC, monitor UO q hr if unconscious or if no - “O+” – men and post-menopausal women
UO w/in 3 hrs of starting IVF - Platelet may be given
9. Record pt’s temp
10. Obtain MSU before starting antibiotics 2. Control of External Hemorrhage
11. If w/ fever, obtain C/S & start broad-spectrum - Rapid PA; cut pt’s clothing to identify areas of
antibiotics (co-amoxiclav or erythromycin) hemorrhage
12. Test for ketonuria - Apply direct, firm pressure over bleeding area or
13. NSS over 8 hrs involved artery
14. KCl infusion in IVF if hypokalemic; monitor HR - Elevate to stop venous & capillary bleeding
15. Start insulin infusion – 1 “U”/ml in NSS via syringe - Immobilize extremity
pump to run at 3 “U”/hr - Tourniquet – last resort; á risk of limb loss
16. Monitor BM q hr - Tag pt w/ skin marking pencil w/ a “T” on
17. If BM doesn’t â w/in 2 hrs, double dose to 6 the forehead indicating location of
“U”/hr tourniquet & time it was applied
18. Once BM < 15 mmols/l, change IV to D5W
19. Continue KCl infusion if K < normal
20. Monitor serum K every time IVF is changed
21. If BM < 6 mmols/l, reduce to 1 “U”/hr

DISABILITY
1. Assess LOC using AVPU
2. Coma – refer to ICU
3. â LOC – cerebral edema; refer to ICU
4. Monitor for seizures – refer to ICU

EXPOSURE
1. Complete hx and PA once stable

HEMORRHAGE
- Results in the reduction of circulating blood
volume; primary cause of SHOCK
- Minor bleeding stops spontaneously except if pt
has bleeding disorder or is taking anticoagulants
- At risk for CARDIAC ARREST due to hypovolemia
w/ secondary anoxia 3. Control of Internal Bleeding
- No external signs of bleeding but exhibits
S/Sx of SHOCK: tachycardia, falling BP, thirst, apprehension, cool,
1. Decreasing arterial pressure moist skin, delayed capillary refill
2. Increasing pulse rate - Administer PRBC (O-) FD
3. Cold, moist skin - Prepare for more definitive tx
4. Delayed capillary refill - Obtain ABG
5. Pallor - Maintain in supine position
6. Thirst
- Close monitoring until hemodynamic status
improves or transport to OR or ICU arrive

MULTIPLE INJURIES
- Requires a team approach
- Injury regarded as the least may be the most
lethal:
- Pelvic fracture may be exsanguinating into
pelvic cavity
- Pneumothorax insidiously increasing in size
affecting both lungs and heart while staff
are focused on treatment of external
lacerations

Goals of Management:
1. Determine extent of injuries
2. Establish priorities of treatment

References:

Smeltzer, Suzanne and Brenda G. Bare. Brunner and

Suddarth’s Textbook of Medical-Surgical Nursing 10 th
Edition, Lippincott Williams & Wilkins.

Carroll, Lisa. Acute Medicine: A Handbook for Nurse

Practitioners, John Wiley & Sons LTD, 2007.