ACLS

Top 10 Posts of 2016

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10. All Shock Explained

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9. Priapism

Priapism

Non-ischemic (high-flow) Ischemic (low-flow)
Physical Exam Typically painless, not fully tumescent Painful, fully tumescent with corpus cavernosa rigidity without involvement of corpus spongiosum and glans penis
Aetiology High-flow priapism is extremely rare and most commonly associated with antecedent trauma including blunt trauma, or resulting from needle injury of the cavernosal artery. Low-flow priapism is caused by impaired relaxation and/or paralysis of cavernosal smooth muscle and in sickle-cell disease
Management NOT Emergency Emergency

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8. 2016 Guidelines

 

 

 

7. Sepsis Six in 60 Minutes: World Sepsis Day – September 13th

Sepsis

NEW SEPSIS PATHWAY

FLUIDS

ANTIBIOTICS

…for every hour you delay, the patient has a 33% increased risk of death!

Capture

 

 

 

LACTATE

6. Did you know about the RULE OF TENS for Fluid Resuscitation in Burns?

Burns Rule of TENS:

1. Estimate burn size (TBSA) to the nearest 10%.
2. Multiply %TBSA x 10 = Initial fluid rate in mL/hr (for adult patients weighing 40 kg to 80 kg).
3. For every 10 kg above 80 kg add 100 mL/hr to the rate.

 

 

5. New 2015 Resuscitation Guidelines Compedium

BLS

 

 

 

 

4. LFTs explained

LFTs Explained

  • LFTs = ‘hepatocellular’ or ‘cholestatic’ arrangement based on the pattern of elevation.
    • Hepatocellular pattern = transaminases >  ALK
  • ALT is generally considered to be more specific to liver damage
  • Magnitude of aminotransferase elevation => guide initial diagnosis: mild (<5x), moderate (5-10x), or marked elevation (>10x)
    • Mild = NAFLD, Drug Induced Liver Injury, Alcohol-Induced Liver Injury
    • Moderate = Alcoholic Hepatitis, Biliary Tract Disease
    • Severe = Acute Viral Hepatitis, Ischemic Injury, Acetaminophen Toxicity

 

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3. The GCS is out-of-stock

GCS

Contrary to common belief, The Glasgow Coma Scale (GCS) is NEVER out-of-stock and the lowest score possible is 3.

  • An intubated patient still gets 1 point for verbal meaning they score 3T…there is nothing like a 2T score (at least not in human beings)
  • The phrase ‘GCS of 11’ is essentially meaningless, and it is important to break the figure down into its components, such as E3V3M5 = GCS 11.
  • The Scale was described in 1974 by Graham Teasdale and Bryan Jennett (Assessment of coma and impaired consciousness. A practical scale. Lancet 1974; 2:81-4.) and is the most reference paper in medical literature

 

 

2. Nairobi Accident Hotspots

Accident Hotspots

The most dangerous time to walk on Nairobi’s streets is on a Friday, around 7am, particularly along  Mombasa Road.

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1. Salter-Harris Fracture (remember the mnemonic SALTR)

  1. Slipped (i.e., through growth plate and not involving bone) / Type I
  2. Above growth plate (i.e., through metaphysis) / Type II (most common)
  3. Lower growth plate (i.e., through epiphysis) / Type III
  4. Through (i.e., through metaphysis growth plate and epiphysis) / Type IV
  5. Rammed (i.e., Crush injury) / Type V (worst prognosis)

 

How to improvise ECG electrodes

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In a resource limited setting, it can be fairly expensive to replenish standard, disposable electrodes used for continuous ECG monitoring.  We have found that one can effectively improvise ECG electrodes using cotton wool swabs.

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ACLS Revision: Subtle ECG findings in ACS

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acs

  • ST-segment elevation in lead aVR portends a worse prognosis in ACS and often predicts the need for CABG.
  • Hyperacute T-waves are not necessarily tall, and small T-waves can still be hyperacute when paired with a low-amplitude QRS complex.
  • The tall T-waves associated with hyperkalemia are sharp, pointy, symmetric, and have a narrow base.
  • When in doubt, get serial ECGs (every 15 minutes) and use adjunctive information.

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Adrenaline: It’s just a suggestion

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Picture1

Epinephrine and other ACLS drugs lead to more patients with ROSC but no increase in the number of patients with good neurologic outcomes after OHCA.

Something that’s very interesting is the actual 2015 ACLS recommendation for epinephrine. It reads, “it is reasonable to consider administering a 1 mg dose of IV/IO epinephrine every 3 to 5 minutes during adult cardiac arrest.” This actually leaves room to not give the medication if the physician thinks it should be withheld.

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ACLS Revision: Symptomatic Bradycardia

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ACLS Revision: Symptomatic Bradycardia

ATROPINE

Atropine administration should not interfere with cardiac pacing.  If there is a favorable response to atropine, the conduction abnormality is likely in the AV node. However, if the escape rhythm is originating at or below the bundle of His, there is unlikely to be a response to atropine as the more distal conducting system is not as sensitive to vagal stimulation. Response to atropine can be predicted by looking at the QRS morphology on a 12 lead ECG.  If the AV block occurs in the AV node or the Bundle of His, the escape rhythm will have a narrow QRS and will likely respond to atropine. Conversely, if the AV block occurs below the bundle of His, the escape rhythm results in a sub-junctional escape rhythm which has a wide QRS and is unlikely to respond to atropine. NOTE: Because atropine can increase cardiac demand, it is contraindicated in patients with complete heart block secondary to myocardial infarction or ischemia.

TRANSCUTANEOUS PACING

  1. Pad Placement and set up: Recommended pad placement for the best capture is anterior/posterior, as shown below. The positive pad is placed posteriorly to the left of the spine, beneath the left scapula. The negative pad is placed anteriorly between the xiphoid process and the left nipple.

Pic 2 Pad Placement

Alternatively, the pads may both be placed anteriorly, with the negative electrode placed in the V6 position and the positive electrode to the right of the sternum, under the clavicle.

Pic 3 Pad Placement

  1. Select Mode: Select the pacemaker button on the box and choose between fixed and demand modes. Fixed mode means that the pacemaker will fire at whatever rate you choose, regardless of the patient’s intrinsic rhythm. Demand mode will sense the patient’s intrinsic rhythm and pace only if needed. Most often you will start in fixed mode.
    • NOTE: If in demand mode, the leads should be placed for continuous ECG so that the pacemaker can sense the patient’s intrinsic rate to pace accordingly (double set up). This prevents the “R on T” phenomenon.
  1. Set rate and output: The initial pacing rate should be set to 60 bpm with the current set to 30 milliamperes (mA). Beware that initially, pacemaker spikes may be visualized without resultant cardiac depolarization. The current can be increased by 5-10 mA at a time until capture is seen as a definite QRS complex and T wave following each pacemaker spike (electrical capture).  Once capture is achieved, check the patient’s pulse (mechanical capture) and correlate with the pulse oximeter, blood pressure  and clinical signs (physiological capture) to ensure that a perfusing rhythm is present.  Final output should be set to 10% above threshold level to ensure continued capture. Human studies have shown that the average current necessary to achieve capture is between 65-100 mA in unstable bradycardias and about 50-70 mA in hemodynamically stable patients.

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The Pregnant Patient

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Teenage-Pregnancies-in-Kenya1-321x214

Modifications of assessment of trauma patients in presence (or suspect) of pregnancy

  1. When indicated a thoracostomy tube should be inserted 1 or 2 intercostal spaces upper than usual.
  2. Vasopressors has to be avoided in pregnancy.
  3. Perform L.U.D (Lateral Uterus Displacement) to relieve Inferior Vena Cava compression.
  4. Transport the severely injuried pregnant patient to an hospital with maternal facility if fetus is viable (≥ 23 weeks).

Resuscitation of the pregnant trauma patient

  1. The utilization of mechanical chest compressors is not recommended.
  2. Continuous LUD should be performed during resuscitation.
  3. No modification in energy level when electrical therapy is needed.
  4. No modification in timing and doses of ACLS drugs.
  5. Fetal assessment is not indicated during resuscitation.
  6. Peri Mortem Cesarean Delivery (PMCD) has to be performed without delay and at the site of cardiac arrest (no transport is indicated), after 4 minutes of ineffective resuscitation attempts.