ACLS REVISION: Post ROSC Care

Once we’ve achieved ROSC our job is not over. Good post-arrest care involves maintaining blood pressure and cerebral perfusion, adequate sedation, cooling and preventing hyperthermia, considering antiarrhythmic medications, optimization of tissue oxygen delivery while avoiding hyperoxia, getting patients to PCI who need it, and looking for and treating the underlying cause.

Mass Casualty Triage – A bit of SALT

Triage is a fast, challenging and unforgiving dance with life and death. Those who have the task will carry the memory of the decisions they were forced to make forever. SALT, which stands for Sort, Assess, Lifesaving interventions, Treatment and/or transport is the four step process for responders to manage mass casualty incidents proposed by the National Association of EMS Physicians as part of a Centers for Disease Control and Prevention sponsored project to use the best available science and expert opinion to develop a standard guideline for mass casualty management.

Tranexamic Acid

TXA is a safe, inexpensive medication that prevents fibrin breakdown.  In traumatic bleeding, it conveys a significant mortality benefit with an impressive NNT for mortality between 7 and 67, depending on injury severity, without apparent serious safety issues.  This benefit is associated with early administration.  TXA should not be given more than three hours after injury as it may increase mortality after this timeframe.  It appears to have equal benefit in a variety of trauma practice environments.

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CRASH-3 Trial: Tranexamic Acid in Mild-Moderate Head Injury

CRASH-3 Trial examined the effect of tranexamic acid on head injury-related death in adults with TBI who were within 3 h of injury, had a Glasgow Coma Scale (GCS) score of 12 or lower or any intracranial bleeding on CT scan, and no major
extracranial bleeding.

The results indicated a reduction in the risk of head injury-related death with tranexamic acid in patients with mild-to-moderate head injury (RR 0·78 [95% CI 0·64–0·95]) but in patients with severe head injury (0·99 [0·91–1·07]) there was no clear evidence of a reduction (p value for heterogeneity 0·030).

The effect of tranexamic acid on head injury-related death stratified by time to treatment and recorded no evidence of heterogeneity (p=0·96). The RR of head injury-related death with tranexamic acid was 0·96 (95% CI 0·79–1·17) in patients randomly assigned within 1 h of injury, 0·93 (0·85–1·02) in those randomly assigned within more than 1 h and 3 h or fewer after injury, and 0·94 (0·81–1·09) in those randomly assigned more than 3 h after injury.

Machakos County: A Model for Emergency Care in the Counties

Machakos County is currently leading in the adoption of the Kenya Emergency Medical Care Policy 2020-2030 developed by the Ministry of Health. Based on the WHO Emergency Care Systems Framework, the Machakos County Emergency Medical Care System is proof that we can have a functioning emergency care system across the different Counties and across the Country.

Anaphylaxis

Anaphylaxis is a sudden, severe allergic reaction that may cause death. The single most effective treatment for an episode of anaphylaxis is administration of epinephrine. Epinephrine is a chemical that arrests the chain of reactions that causes the signs and symptoms of anaphylaxis.

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Where did the IV fluid go…

DID YOU KNOW: In managing shock, for every liter of normal saline given, only 180mls remains intravascular (your normal adult intravascular volume is approx. 5L). So in hypovolaemic patients…give loads of fluids…for blood loss, give blood early, the best natural colloid.

Oxygen…THE DRUG!

DID YOU KNOW:

  • Hospital Oxygen is NOT FREE
  • At an SPO2 of 94%, additional oxygen is of NO BENEFIT. At this level, the standard dissociation curve is relatively flat, which means that the oxygen content of the blood does not change significantly even with large increases in oxygen.
  • Oxygen DOES NOT CURE DIFFICULTY IN BREATHING (DYSPNOEA), just HYPOXIA.
  • Oxygen should be delivered to achieve a target saturation of 94–98% for most acutely ill patients or 88–92% for those at risk of hypercapnic respiratory failure e.g. COPD
  • Humidification of supplemental oxygen commonly delivered by bubbling oxygen through either cold or warm sterile water before it reaches the patient should NOT be used because there is NO EVIDENCE of a clinically significant benefit but there is a risk of infection.

DOSE:

  • Nasal prongs delivers 4% additional oxygen per 1 litre of flow i.e. at 1L/min it delivers 24% (20% is already in the air), at 2L per min it delivers 28%, 3L/min 32%…and so on so at 6L/min it delivers 44%
  • A simple face mask should be used at a minimum of 6L/min (normal minute ventilation) to prevent the patient from breathing back their own CO2.
  • Application of a self inflating Bag-Valve-Mask on a patient’s face without compressing the bag is called suffocation. Due to the valves system, oxygen is only delivered ON COMPRESSING THE BAG
  • Pulse oximeters consist of two light-emitting diodes, one in the red range and one in the infrared range, and a detector.  Oxygenated and deoxygenated haemoglobin absorb light at different wavelengths differently. Deoxygenated or ‘‘blue’’ blood absorbs light maximally in the red band, whereas Oxygenated or ‘‘red’’ blood absorbs light maximally in the infrared band. The ratio of absorption of the two wavelengths of light are then compared with an algorithm in the microprocessor generated by empirically measuring the absorption in healthy volunteers at varying degrees of directly measured arterial oxygen saturation. The displayed value is usually an average based on the previous 3 to 6 seconds of recording.

HARMFUL EFFECTS:

  • Nonhypoxic heart attack victims treated with oxygen endure a 25 to 30% more heart damage than patients not given oxygen
  • Oxygen supplementation to nonhypoxic patients with mild or moderate strokes may increase mortality.
  • High-dose oxygen therapy to produce hyperoxaemia (above normal oxygen saturation) can cause absorption atelectasis
  • Oxygen is liberally administered to many critically ill patients, thereby exposing them to supranormal arterial oxygen levels.
  • Hyperoxia also results in the formation of reactive oxygen species, which adversely affect the pulmonary, vascular, cnetral nervous, and immune systems.
  • Though the optimal PaO2 remains unknown, recent evidence indicates that hyperoxia is associated with increased mortality in post-cardiac arrest, CVA, acute coronary syndrome, and traumatic brain injury patients.
  • Take Home Point: Carefully titrate oxygen to the lowest tolerable level to meet the patient’s needs.