Normal (Abnormal) Saline vs. Ringer’s Lactate

The choice of crystalloid fluid for volume resuscitation is debated often. With rising concern about the effect of hyperchloremic metabolic acidosis associated with normal saline, clinicians more commonly are opting for balanced crystalloids, such as lactated Ringer’s solution or Plasma-Lyte. 

American Heart Association Guidelines for CPR & Emergency Cardiovascular Care 2017

 

These highlights summarize the key issues and changes in the adult and pediatric basic life support (BLS) 2017 focused updates to the American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC).

 

Management of Crush Injury/Syndrome

Crush syndrome is a life and limb-threatening condition that can occur as a result of entrapment of the extremities accompanied by extensive damage of a large muscle mass. It can develop following as little as 1 hour of entrapment. Effective medical care is required to reduce the risk of kidney damage, cardiac arrhythmia, and death. Management includes;

  • Fluids: IV fluid to provide 1L/h for 24 to 48 hours (depending on evacuation availability)
  • Equipment: ECG, laboratory tests for serum potassium and urine myoglobin, Foley catheter with graduated collection system, tourniquets
  • Medications: hyperkalemia
  • Manage Pain
  • Give Antibiotics
  • Continuous monitor with portable monitor; 15-minute to hourly vital signs, examination, urine output documented on flow sheet

 

Intraosseous Access 101

  • IO access provides rapid vascular access in a variety of emergency situations.
  • There are several types of IO devices that can be used.
  • The humeral site is generally the least painful and quickest to access
  • All resuscitation and anaesthetic drugs can be given via the IO route.
  • Fluids need to be administered under pressure.
  • All devices need to be monitored and a clear handover given.

 

Did you know Adrenaline doesn’t work for Cardiac Arrest?

Adrenaline may improve return of spontaneous circulation, but it does not improve survival to discharge or neurologic outcome. The timing of epinephrine may affect patient outcome, but Basic Life Support measures are the most important aspect of resuscitation and patient survival.

 

Post ROSC

System Action
Airway Intubate → Ventilation tidal volume @ 6-8 mL/kg
Place OG or NG tube
Confirm endotracheal and OG/NG tube placement with chest x-ray
Breathing SpO2 goal >94% → adjust PEEP & FiO2 to achieve goal
EtCO2 goal 30-40 mmHg → adjust respiratory rate to achieve
Circulation 12-lead ECG → Activate cardiac catheterization lab for STEMI; consult cardiology for all other patients
SBP goal >90 mmHg (MAP > 65 mmHg) → Use fluids, norepinephrine infusion, then epinephrine infusion to achieve goal
Place central line
Place arterial line
Perform point of care ultrasound with the cardiac, lung, and IVC views
Send labs, which includes an arterial blood gas and serum lactate
Place Foley catheter → Goal urine output 0.5-1 mL/kg/hr
Consider CT chest angiography to rule-out a pulmonary embolism
Disability Begin cooling → Goal temperature 32–36°C
Consider head CT