73 yrs old male found unconscious by his wife. CPR started by a neighbour with pre arrival CPR instructions provided by dispatcher. We found him in asystolic cardiac arrest. Established mechanical chest compressions (MCC), ventilated through an 8.0 ET tube, placed an intraosseus access, 10 min of ALS and 2 mg of epinephrine later, on the monitor appears an organised rhythm at 40 bpm (narrow junctional shape), NO CENTRAL PULSE. After 2 min (CPR still going) same rhythm stil NO CENTRAL PULSE but this time, during the MCC pause, a subcostal view of the heart was obtained (sorry for the quality of the images but were recorded during the code and I’m not an expert but just an ultrasound user)
As you can see the heart is moving and the right ventricle is almost the double of the left one. Due also to the clinical history of a recent surgical knee replacement the most probable origine of the cardiac arrest is PE. We decided to continue chest compressions, but to stop epinephrine at 1 mg dose, starting push doses of 0,1 mg till the return of a central pulse. After 5 min a strong carotid pulse appeared and this is the ultrasound view of the heart at that moment
The patient arrived to the hospital sedated and paralysed in assisted pressure control ventilation. You can see on the monitor the rest of vital signs.
No follow up yet.
You can read more about PEA and Pseudo-PEA on MEDEST
Forget ACLS guidelines if you are dealing with Pulseless Electric Activity. Part 1.
Forget ALS Guidelines when dealing with PEA. Part 2.
Le tue opinioni sono il nostro valore aggiunto!
MEDEST 
Beyond Advanced Cardiac Life Support. Do we have to change our practice in COVID Era?
3 MagMain changes in recommendations
Personal Protective Equipment for Advanced Life Support interventions need to be at maximum level of protection of full body, eyes and airways.
CAT 3 level of protection 4 (at least) for the full body
FPP2/N95 airway filter for team members who are NOT directly involved in airway management, ventilation or manual chest compressions
FPP3/N99 airway filter for providers who are directly involved in airway management, ventilation and manual chest compressions.
Face shield and protective googles are strongly suggested
Mechanical Chest compressors devices are the gold standard to perform cardiac massage. They reduce contacts and contamination risk and team member exposure to contaminants.
Adhesive disposable pads are the only option to check rhythm and deliver shock. Dispose non-disposable, manual pads.
Passive O2 administration (via simple face mack at a rate of 15l/m) during chest compressions is the first option over bag mask ventilation when performing Basic Life Support waiting for advanced airway management.When using a Bag Valve Mask always put a HEPA/HME filter between Bag and mask to avoid contamination
Hold chest compressions when performing airway managment
Cover patient head with a transparent plastic foil to minimise virus spreading and contamination when performing airway management and bag mask ventilation
Tracheal intubation using a video laryngoscope is the first line option for advanced airway management to minimise contamination.
If video laryngoscope is not available Extraglottic devices are an acceptable first line option
Use all the implementation to improve intubation first passage success:
Video laringoscopy
Bougie
RAMP positioning
Suctioning (SALAD technique)
Use all the implementation to improve Extraglottic device placement
Laryngoscope for tongue displacement and mouth opening (DO NOT USE hands)
Deflate cuff
Lubrificate the device
Whatever plan you apply use an HEPA/HME filter immediately after the ventilation device
Use disposable cover and disposable gel to perform Ultrasound during chest compressions
Condividi:
Mi piace:
Tag:ACLS, COVID-19, Emergency Medicine guidelines, emergenza, emergenza sanitaria territoriale, medicina d'urgenza, medicina d'urgenza preospedaliera