Resuscitation ABCs William Beaumont Hospital Department of Emergency Medicine.

ResuscitationResuscitationABCsABCs

William Beaumont HospitalWilliam Beaumont Hospital

Department of Emergency MedicineDepartment of Emergency Medicine

What we are covering in a What we are covering in a nutshell…nutshell…

AirwayAirway

BreathingBreathing

Circulation and ShockCirculation and Shock

Airway: Decision to IntubateAirway: Decision to Intubate Failure to maintain or protect airwayFailure to maintain or protect airway

Reposition the patient and apply the jaw Reposition the patient and apply the jaw thrust or chin lift maneuver to open the thrust or chin lift maneuver to open the airwayairway

Failure to ventilate or oxygenateFailure to ventilate or oxygenate Hypoxemia not responding to above Hypoxemia not responding to above

maneuvers or application of external O2maneuvers or application of external O2 Fatigue or tiring out secondary to Fatigue or tiring out secondary to

tachypnea, excessive work of breathingtachypnea, excessive work of breathing Anticipate the need for intubationAnticipate the need for intubation

Status epilepticus, OD, multiple trauma, Status epilepticus, OD, multiple trauma, sepsis…sepsis…

Sniffing PositionSniffing Position

The sniffing position is achieved byThe sniffing position is achieved by A) Extending the head whileA) Extending the head while B) Simultaneously flexing the neckB) Simultaneously flexing the neckNeck flexion is maintained by placing Neck flexion is maintained by placing

padding behind the headpadding behind the headContraindicated: potential C-spine injuryContraindicated: potential C-spine injury

Difficult Intubation:Difficult Intubation:Physical CharacteristicsPhysical Characteristics

Anatomically abnormal faciesAnatomically abnormal facies Neck TraumaNeck Trauma Prominent IncisorsProminent Incisors Receding Mandible or Small JawReceding Mandible or Small Jaw C-spine immobilizationC-spine immobilization Short and thick neckShort and thick neck Large tongueLarge tongue

Difficult BVM CharacteristicsDifficult BVM Characteristics

EdentulousEdentulous ObesityObesity History of snoringHistory of snoring Beards or facial hairBeards or facial hair Facial or neck traumaFacial or neck trauma Obstructive airway disease or Obstructive airway disease or

bronchospasmbronchospasm 33rdrd trimester pregnancy trimester pregnancy

Mallampati Signs for Mallampati Signs for Difficult IntubationDifficult Intubation

Comparing Pediatric and Adult Comparing Pediatric and Adult AirwaysAirways

Anatomic differencesAnatomic differences Small mouth plus proportionately larger soft Small mouth plus proportionately larger soft

tissues and structures (tongue and tonsils)tissues and structures (tongue and tonsils) Airway location and vocal cords are higher Airway location and vocal cords are higher

and more anterior in childrenand more anterior in children Most narrow portion of the airway in kids is Most narrow portion of the airway in kids is

at the cricoid cartilage – therefore uncuffed at the cricoid cartilage – therefore uncuffed ET tubes should be used (adults most ET tubes should be used (adults most narrow below the cricoid at the vocal cords)narrow below the cricoid at the vocal cords)

Pediatric cricothyroid membrane is small, Pediatric cricothyroid membrane is small, difficult to palpate, and incise so difficult to palpate, and incise so cricothyroidotomy is contraindicated <cricothyroidotomy is contraindicated < 8 8 y/oy/o

Comparing Pediatric and Adult Comparing Pediatric and Adult AirwaysAirways

Anatomic Differences cont…Anatomic Differences cont… Pediatric trachea is shorter so is more prone Pediatric trachea is shorter so is more prone

to R mainstem intubation and tube to R mainstem intubation and tube dislodgementdislodgement

Larger occiput causes passive flexion of the Larger occiput causes passive flexion of the c-spine and buckling of the airway -> sniffing c-spine and buckling of the airway -> sniffing position to open the airway and align the position to open the airway and align the axis of the oropharynx/larynx/vocal cordsaxis of the oropharynx/larynx/vocal cords

Pediatric AirwayPediatric Airway

Estimating ET tube sizeEstimating ET tube size Broselow tapeBroselow tape (age+16)/4(age+16)/4 ETT size estimation based upon the ETT size estimation based upon the

width of the child’s fifth fingernailwidth of the child’s fifth fingernail

Endotracheal IntubationEndotracheal Intubation

Purpose – to achieve definitive airway Purpose – to achieve definitive airway control (LMA and combitube are NOT)control (LMA and combitube are NOT)

IndicationsIndications Respiratory failureRespiratory failure Airway protection in an unconscious Airway protection in an unconscious

patientpatient Decrease the work of breathingDecrease the work of breathing Therapeutic interventions such as Therapeutic interventions such as

hyperventilation for HI or to protect hyperventilation for HI or to protect the airway during diagnostic studiesthe airway during diagnostic studies

Straight vs Curved BladesStraight vs Curved Blades Straight BladeStraight Blade

Preferred in infants and kids < 8 yoPreferred in infants and kids < 8 yo tip of the blade passes over the epiglottis and tip of the blade passes over the epiglottis and

tongue to physically lift them out of the waytongue to physically lift them out of the way

Curved BladeCurved Blade Fits into the vallecula between the tongue and Fits into the vallecula between the tongue and

epiglottis to lift the palate and soft tissues epiglottis to lift the palate and soft tissues anteriorlyanteriorly

Mechanically difficult to use in obese adults Mechanically difficult to use in obese adults and children with lots of floppy soft tissue and children with lots of floppy soft tissue structuresstructures

RSI = Rapid Sequence RSI = Rapid Sequence IntubationIntubation

Definition = systematic protocol using sedatives Definition = systematic protocol using sedatives and paralytics to increase chances of successful and paralytics to increase chances of successful intubation and decrease the risk of aspiration intubation and decrease the risk of aspiration (hopefully)(hopefully)

Indications – airway control or compromise, Indications – airway control or compromise, shock, head injury, impending respiratory arrestshock, head injury, impending respiratory arrest

Contraindications – physically obstructed Contraindications – physically obstructed airway, severe mid facial fractures, neck or airway, severe mid facial fractures, neck or throat surgery or traumathroat surgery or trauma

When to think twice – short, fat bull neck, c When to think twice – short, fat bull neck, c spine trauma, oral abscess or masses, ludwig’s spine trauma, oral abscess or masses, ludwig’s angina, facial burnsangina, facial burns

The 6 P’s of RSIThe 6 P’s of RSI

11. Prepare. Prepare Equipment – suction, blade, ETT, monitor, Equipment – suction, blade, ETT, monitor,

nursing staff, drugsnursing staff, drugs

2. Pre Oxygenate2. Pre Oxygenate Provides a period of time after the Provides a period of time after the

patient becomes apneic in which they will patient becomes apneic in which they will remain adequately oxygenatedremain adequately oxygenated

BVM or 100% O2 for 3-5 minutesBVM or 100% O2 for 3-5 minutes

The 6 P’s of RSIThe 6 P’s of RSI3. 3. Pre TreatmentPre Treatment Sedation – opioids, benzos, ketamine, Sedation – opioids, benzos, ketamine,

etomidateetomidate Head Injury or Increased ICP – lidocaine, Head Injury or Increased ICP – lidocaine,

fentanyl, defasciculating dose of fentanyl, defasciculating dose of paralyticparalytic

Atropine for Kids prior to intubation to Atropine for Kids prior to intubation to prevent vagal induced bradycaridaprevent vagal induced bradycarida

4. Paralysis4. Paralysis Depolarizing Agents = SuccinylcholineDepolarizing Agents = Succinylcholine Nondepolarizing Agents = pancuronium, Nondepolarizing Agents = pancuronium,

vecuronium, but mostly ROCURONIUMvecuronium, but mostly ROCURONIUM

SuccinylcholineSuccinylcholine Mimics Ach at the neuromuscular Mimics Ach at the neuromuscular

junctionjunction Onset of action is 20-30 secondsOnset of action is 20-30 seconds Duration is 90-120 secondsDuration is 90-120 seconds Dose 1-1.5mg/kg for adults and 1.5-Dose 1-1.5mg/kg for adults and 1.5-

2mg/kg for kids (remember to pre treat 2mg/kg for kids (remember to pre treat with atropine)with atropine)

Side Effects Side Effects histamine release causing hypotensionhistamine release causing hypotension rise in ICPrise in ICP Release of K from cells – precaution in burn Release of K from cells – precaution in burn

patients, diabetics, patients found down patients, diabetics, patients found down (rhabdo)(rhabdo)

Nondepolarizing Agents – Nondepolarizing Agents – RocuroniumRocuronium

Reversible, competitive antagonist of Reversible, competitive antagonist of Ach at the neuromuscular junctionAch at the neuromuscular junction

Slower onset of action but longer actingSlower onset of action but longer acting Can be reversed (rarely) with Can be reversed (rarely) with

edrophoniumedrophonium Onset is 45-60 secondsOnset is 45-60 seconds Duration is 30 minutesDuration is 30 minutes Dose is 0.6-1.0 mg/kg for adults and kidsDose is 0.6-1.0 mg/kg for adults and kids

The 6 P’s of RSIThe 6 P’s of RSI

5. Pass the Tube5. Pass the Tube Assess the depth of paralysis Assess the depth of paralysis

through degree of relaxation of the through degree of relaxation of the jaw muscle or eye lidsjaw muscle or eye lids

Apply cricoid pressure = Sellick Apply cricoid pressure = Sellick Maneuver to prevent aspiration Maneuver to prevent aspiration (not maneuvering the trachea)(not maneuvering the trachea)

Visualize the cordsVisualize the cords Pass the tube into the tracheaPass the tube into the trachea

The 6 P’s of RSIThe 6 P’s of RSI

6. Position Check6. Position Check See the tube pass through the cordsSee the tube pass through the cords Check for symmetric chest wall rise and Check for symmetric chest wall rise and

fall with baggingfall with bagging Check for equal bilateral breath soundsCheck for equal bilateral breath sounds End tidal CO2 detection (color change)End tidal CO2 detection (color change) CXR for position of ETTCXR for position of ETT

The 6 P’s of RSIThe 6 P’s of RSI

Pitfalls – OK this is 7, we made this Pitfalls – OK this is 7, we made this one upone up Not preparing and checking your Not preparing and checking your

equipmentequipment Forgetting cricoid pressureForgetting cricoid pressure Over aggressively BVM causing Over aggressively BVM causing

gastric distension and increased risk gastric distension and increased risk of aspirationof aspiration

CricothyroidotomyCricothyroidotomy

Creation of an opening in the Creation of an opening in the cricothyroid membrane for placement of cricothyroid membrane for placement of a trach tube when oral intubation fails a trach tube when oral intubation fails or is contraindicated or is contraindicated

Incidence – 1% of all ED intubationsIncidence – 1% of all ED intubations Contraindications (relative)Contraindications (relative)

distorted neck anatomy distorted neck anatomy pre existing infectionpre existing infection coagulopathycoagulopathy children < 10 years oldchildren < 10 years old

CricothyroidotomyCricothyroidotomy

1.1. Locate cricothyroid Locate cricothyroid cartilagecartilage

2.2. 3-4 cm vertical skin 3-4 cm vertical skin incisionincision

3.3. Horizontal stab thru Horizontal stab thru cricothyroid membranecricothyroid membrane

4.4. Insert hemostat & dilate Insert hemostat & dilate opening horizontally opening horizontally then verticallythen vertically

5.5. Insert #4 Shiley trach Insert #4 Shiley trach tube or 5 mm ET tube tube or 5 mm ET tube (cut short) & verify (cut short) & verify positionposition

6.6. Inflate balloon & secure Inflate balloon & secure tubetube

Questions?Questions?

Let’s move on to Let’s move on to circulationcirculation

CirculationCirculationShockShock – a pathologic state that initiates a – a pathologic state that initiates a

sequence of stress responses in the body sequence of stress responses in the body designed to preserve flow to vital organsdesigned to preserve flow to vital organs

4 Types of Shock4 Types of Shock Hypovolemic - hemorrhagic, Hypovolemic - hemorrhagic,

nonhemorrhagicnonhemorrhagic Distributive – septic, anaphylactic, Distributive – septic, anaphylactic,

neurogenicneurogenic Cardiogenic – arrhythmias, other – AMI, Cardiogenic – arrhythmias, other – AMI,

cardiomyopathy, ODcardiomyopathy, OD Obstructive – tension pneumothorax, Obstructive – tension pneumothorax,

cardiac tamponade, pulmonary embolus, cardiac tamponade, pulmonary embolus, ductal dependentductal dependent

Septic ShockSeptic Shock

Septic shock – patient with sepsis who Septic shock – patient with sepsis who remains hypotensive (SBP < 90) despite remains hypotensive (SBP < 90) despite adequate fluid resuscitationadequate fluid resuscitation

Sepsis – patient with presumed or known Sepsis – patient with presumed or known infection plus 2 or more SIRS criteriainfection plus 2 or more SIRS criteria

SIRS criteria SIRS criteria – – systemic inflammatory response systemic inflammatory response syndromesyndrome

1) temp > 38*C or < 36*C1) temp > 38*C or < 36*C 2) HR > 90 bpm2) HR > 90 bpm 3) RR > 20/ min or PaCo2 < 343) RR > 20/ min or PaCo2 < 34 4) WBC > 12,000 or < 4,0004) WBC > 12,000 or < 4,000

Septic ShockSeptic Shock

PathophysiologyPathophysiology a focus of infection causes release of a focus of infection causes release of

large amount of toxinlarge amount of toxin the body reacts by releasing mediators the body reacts by releasing mediators

and humoral defenses such as and humoral defenses such as complement, cytokines , and platelet complement, cytokines , and platelet activating factoractivating factor

Clinical FeaturesClinical Features hot flushed skin, hyperthermia or hot flushed skin, hyperthermia or

hypothermia, tachycardia, tachypnea, hypothermia, tachycardia, tachypnea, wide pulse pressure, mental status wide pulse pressure, mental status changeschanges

Septic ShockSeptic Shock

TherapyTherapy Attention to ABC’s – assess Attention to ABC’s – assess

ventilation and oxygenationventilation and oxygenation Aggressive fluid administration – Aggressive fluid administration –

Normal saline fluid boluses of 20cc/kgNormal saline fluid boluses of 20cc/kg may need to repeat 2-3 times until may need to repeat 2-3 times until

SBP>90SBP>90 Empiric antibiotics – cover Gm + and Empiric antibiotics – cover Gm + and

Gm –Gm – Lab evaluation – CBC, BMP, U/A, urine Lab evaluation – CBC, BMP, U/A, urine

& blood cultures, CXR, lactic acid& blood cultures, CXR, lactic acid

Septic ShockSeptic Shock PressorsPressors

Norepinephrine - first line drugNorepinephrine - first line drug 2-20 mcg/kg/min2-20 mcg/kg/min

Dopamine – may add to norepinephrine or Dopamine – may add to norepinephrine or change to this based on clinical responsechange to this based on clinical response

5-20 mcg/kg/min 5-20 mcg/kg/min Vasopressin – should not be sole agent Vasopressin – should not be sole agent Phenylephrine – used in patients with Phenylephrine – used in patients with

excessive tachycardia from pressors excessive tachycardia from pressors

Consider steroids Consider steroids sepsis associated with adrenal insufficiency sepsis associated with adrenal insufficiency

hydrocortisone 100mg IVP or hydrocortisone 100mg IVP or dexamethazone 4 mg IVPdexamethazone 4 mg IVP

Hemorrhagic ShockHemorrhagic Shock

Defined – blood loss of significant magnitude to Defined – blood loss of significant magnitude to overcome normal physiologic compensatory overcome normal physiologic compensatory response and compromise tissue perfusionresponse and compromise tissue perfusion

Blood loss triggers increased cardiac rate & Blood loss triggers increased cardiac rate & force of contractionforce of contraction

To maintain BP, redistribution of blood flow To maintain BP, redistribution of blood flow occurs to preserve vital organ function, occurs to preserve vital organ function, conserve water and sodium, and control blood conserve water and sodium, and control blood loss. loss.

Baroreceptors sense fall in BP and release Baroreceptors sense fall in BP and release norepinephrine. norepinephrine.

Norepinephrine increases CO and stimulates Norepinephrine increases CO and stimulates renin secretion (increasing Na & H2O renin secretion (increasing Na & H2O reabsorption)reabsorption)

Hemorrhagic ShockHemorrhagic Shock

Norepinephrine causes vasoconstriction Norepinephrine causes vasoconstriction especially in the splanchnic blood especially in the splanchnic blood vessels which can increase circulating vessels which can increase circulating blood volume by 20-30%blood volume by 20-30%

Acute hemorrhage also causes local Acute hemorrhage also causes local activation of the clotting cascade so activation of the clotting cascade so blood vessels contract and plateletes blood vessels contract and plateletes adhere to damaged vessels.adhere to damaged vessels.

Hemorrhagic ShockHemorrhagic ShockSkin cool, clammy, mottled Skin cool, clammy, mottled Tachycardia, narrow pulse pressureTachycardia, narrow pulse pressureRR > 22 PaCo2 < 32RR > 22 PaCo2 < 32Site of hemorrhage not always obviousSite of hemorrhage not always obvious

TreatmentTreatment Control hemorrhageControl hemorrhage Rapid infusion of several liters NS in adults Rapid infusion of several liters NS in adults

or successive 20cc/kg boluses in kidsor successive 20cc/kg boluses in kids If still hypotensive after aggressive fluid If still hypotensive after aggressive fluid

resuscitation, then transfuse 5-10 ml/kg resuscitation, then transfuse 5-10 ml/kg PRBC type specific PRBC type specific

If uncontrolled hemorrhage, then use If uncontrolled hemorrhage, then use uncrossmatched blood (type O neg)uncrossmatched blood (type O neg)

Hemorrhagic ShockHemorrhagic Shock

Class 1 – 15% loss – mild tachycardia Class 1 – 15% loss – mild tachycardia only, rapid response to fluidsonly, rapid response to fluids

Class 2 – 15-30% loss –Class 2 – 15-30% loss –PP (PP (DBP and DBP and PVR), subtle MS changes, cap refill > 2 sPVR), subtle MS changes, cap refill > 2 s

Class 3 – 30-40% loss – Class 3 – 30-40% loss – SBP, marked MS SBP, marked MS changes, transient response to IVFchanges, transient response to IVF

Class 4 - > 2 L loss – obtunded, clammy, Class 4 - > 2 L loss – obtunded, clammy, marked hypotension, narrow PP, minimal marked hypotension, narrow PP, minimal or no response to IVF – needs bloodor no response to IVF – needs blood

CARDIOGENIC SHOCKCARDIOGENIC SHOCK Definition: results when >40% myocardial Definition: results when >40% myocardial

necrosis from ischemia, inflammation or toxins necrosis from ischemia, inflammation or toxins

Primary cause – pump failurePrimary cause – pump failure Cardiogenic shock produces same circulatory Cardiogenic shock produces same circulatory

and metabolic alterations as hemorrhagic shockand metabolic alterations as hemorrhagic shock

Clinical Clinical distended neck veins imply CHF, PE, distended neck veins imply CHF, PE,

tamponadetamponade muffled heart tones think tamponademuffled heart tones think tamponade fever & new murmur – endocarditisfever & new murmur – endocarditis loud machine like murmur – papillary loud machine like murmur – papillary

muscle rupturemuscle rupture asymmetric breath sounds – pneumothoraxasymmetric breath sounds – pneumothorax Beck’s triad (pericardial tamponade)– JVD, Beck’s triad (pericardial tamponade)– JVD,

hypotension, muffled heart toneshypotension, muffled heart tones

CARDIOGENIC SHOCKCARDIOGENIC SHOCK

TREATMENT TREATMENT O2, PEEP for CHF, O2, PEEP for CHF, intubate for impending respiratory failure intubate for impending respiratory failure Inotropic support - dobutamine, dopamineInotropic support - dobutamine, dopamine Treat underlying cause – AMI, PETreat underlying cause – AMI, PE Inamrinone (Inocor) for refractory Inamrinone (Inocor) for refractory

hypotension, may improve CO by hypotension, may improve CO by increasing cAMP, no tachyphylaxis and no increasing cAMP, no tachyphylaxis and no increased myocardial O2 consumptionincreased myocardial O2 consumption

Consider aortic balloon pump – improves Consider aortic balloon pump – improves diastolic coronary perfusion and cardiac diastolic coronary perfusion and cardiac output by 30%output by 30%

ANAPHYLACTIC SHOCKANAPHYLACTIC SHOCK Results from IgE mediated systemic Results from IgE mediated systemic

response to an allergenresponse to an allergen IgE causes mast cells to release IgE causes mast cells to release

histamine resulting in vasodilation, histamine resulting in vasodilation, bronchoconstriction, capillary leak into bronchoconstriction, capillary leak into interstitial spaceinterstitial space

Clinical – the quicker the symptoms Clinical – the quicker the symptoms manifest, the more severe the reactionmanifest, the more severe the reaction

Symptoms - flushing, warmth, urticaria, Symptoms - flushing, warmth, urticaria, pruritis, dyspnea, wheezing, pruritis, dyspnea, wheezing, angioedema, tachycardia, tachypnea, angioedema, tachycardia, tachypnea, hypotensionhypotension

Anaphylactic Shock TherapyAnaphylactic Shock Therapy

Benadryl/Cimetadine – H1 H2 blockers Benadryl/Cimetadine – H1 H2 blockers prevent urticaria, reduce prevent urticaria, reduce

bronchoconstriction, reduce fluid bronchoconstriction, reduce fluid transudationtransudation

Corticosteroids Corticosteroids Nebulized B2 agonist – reduce bronchospasmNebulized B2 agonist – reduce bronchospasm EpinephrineEpinephrine

alpha agonist – reverses hypotension by alpha agonist – reverses hypotension by vasoconstrictionvasoconstriction

beta agonist – bronchodilation, positive beta agonist – bronchodilation, positive ionotrope and chronotropeionotrope and chronotrope

stop T cell and mast cell activationstop T cell and mast cell activation reduce bronchial inflammationreduce bronchial inflammation

CENTRAL NEUROGENIC CENTRAL NEUROGENIC SHOCKSHOCK

Definition – loss of neurologic function and Definition – loss of neurologic function and autonomic tone below the level of the spinal autonomic tone below the level of the spinal cord lesioncord lesion

Hypotension from spinal shock is a diagnosis Hypotension from spinal shock is a diagnosis of exclusion in the trauma patient. of exclusion in the trauma patient.

It is caused by loss of vasomotor tone and lack It is caused by loss of vasomotor tone and lack of reflex tachycardia from disruption of of reflex tachycardia from disruption of autonomic ganglia.autonomic ganglia.

Clinical – flaccid paralysis, loss of DTR’s, loss of Clinical – flaccid paralysis, loss of DTR’s, loss of bladder tone, bradycardia, hypotension, bladder tone, bradycardia, hypotension, hypothermia, skin warm & dry, good urine hypothermia, skin warm & dry, good urine outputoutput

Central Neurogenic ShockCentral Neurogenic Shock

TreatmentTreatment Adequate fluid replacementAdequate fluid replacement Atropine – treat vagal mediated Atropine – treat vagal mediated

bradycardia bradycardia Ephedrine/Phenylephrine – promote Ephedrine/Phenylephrine – promote

vasoconstriction and promote cord vasoconstriction and promote cord perfusionperfusion

Methylprednisolone - given w/in 8 hrs of Methylprednisolone - given w/in 8 hrs of injury shown to improve neurologic injury shown to improve neurologic recoveryrecovery

BURNSBURNS Fluid ResuscitationFluid Resuscitation Parkland Formula for BurnsParkland Formula for Burns 4ml/kg x (% BSA burned)4ml/kg x (% BSA burned) give ½ of fluid in first 8 hoursgive ½ of fluid in first 8 hours Rule of NinesRule of Nines Technique for estimating the extent Technique for estimating the extent of body surface area burned of body surface area burned

The difference between the BSA of an adult The difference between the BSA of an adult andand

an infant reflects the size of the infant’s an infant reflects the size of the infant’s headhead

which is proportionately larger than an which is proportionately larger than an adult. adult.

RULE OF NINESRULE OF NINESDiagram #5

PEDIATRIC RESUSCITATION DOSESPEDIATRIC RESUSCITATION DOSES

Defibrillation 2J/kg then 4J/kg, 4J/kgDefibrillation 2J/kg then 4J/kg, 4J/kg

Epinephrine .01mg/kg (1:10,000)Epinephrine .01mg/kg (1:10,000)

Atropine .01mg/kgAtropine .01mg/kg

GlucoseGlucose D10 2-4ml/kg (not D50)D10 2-4ml/kg (not D50) Fluid 20-40 ml/kg NS bolusFluid 20-40 ml/kg NS bolus

Drugs you can give thru an ET tube Drugs you can give thru an ET tube (NAVEL)(NAVEL)

Narcan Atropine Valium Epi LidocaineNarcan Atropine Valium Epi Lidocaine

HYPERKALEMIAHYPERKALEMIA

K level K level EKG changesEKG changes 5.6 – 6.0 tall peaked T waves5.6 – 6.0 tall peaked T waves 6.0 – 7.0 long PR & QT6.0 – 7.0 long PR & QT decreased P wavesdecreased P waves ST segment ST segment

depressiondepression 7.0 – 8.0 idioventricular rhythm 7.0 – 8.0 idioventricular rhythm wide QRSwide QRS10.0 and up sine wave10.0 and up sine wave

HYPERKALEMIAHYPERKALEMIA

TREATMENT OF TREATMENT OF HYPERKALEMIAHYPERKALEMIA KayexalateKayexalate

ion exchange resin given po or prion exchange resin given po or pr each gram exchanges with & eliminates 1mEq Keach gram exchanges with & eliminates 1mEq K

Insulin/Glucose/HCO3 Insulin/Glucose/HCO3 – use if EKG changes or – use if EKG changes or unstableunstable

glucose enters cells & pulls K with itglucose enters cells & pulls K with it dose: Insulin 10 U IV, Glucose 1 amp D50, 1 dose: Insulin 10 U IV, Glucose 1 amp D50, 1

amp HCO3amp HCO3

Ca gluconate/ Ca Cl Ca gluconate/ Ca Cl – use if hypotension, CP, SOB,– use if hypotension, CP, SOB, lethargy, coma lethargy, coma

10ml of 10% Ca Cl (1 amp) slowly over 10-20 min10ml of 10% Ca Cl (1 amp) slowly over 10-20 min if patient on Digoxin, be very cautious – Calcium if patient on Digoxin, be very cautious – Calcium

potentiates toxic effects of digoxin on the heartpotentiates toxic effects of digoxin on the heart

THE ENDTHE END