Posts Tagged cardiac arrest

Management of Traumatic Arrest

This week I am discussing the management of traumatic arrest. A whole host of things need to happen in rapid succession, but two things you definitely should not be doing are closed-chest CPR or giving ACLS medications. We discuss who gets a thoracotomy, what to do if a thoracotomy is not indicated, and when to stop.

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The 2010 ACLS & BCLS Guidelines

The brand new ACLS & BCLS guidelines were published last week. Not huge changes, but some good stuff! The free full text is available at the Circulation website. It takes hours to make your way through all of it. I boiled it down to just the facts and posted a summary on the EMCrit site. In this EMCrit Podcast I discuss some of the highlights that I think are particularly important.

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The Management of the Intra-Arrest

This week we talk about managing the intra-arrest period of cardiac arrest. My paradigm has changed dramatically over the past few years. In the past, I viewed the arrest as a period to teach my residents how to place a subclavian central line, how to intubate when the patient is moving, and how to cram as many drugs as possible into a patient in a short period of time.

Looking at how I manage an arrest today, so much has changed. LMAs instead of tubes, IOs instead of central lines, and so much more.

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Top Ten Tips on Therapeutic Hypothermia

At this stage of the game, if your hospital is not offering hypothermia to out-of-hospital cardiac arrests, you are probably lagging behind optimal care. For shockable rhythms, you essentially double your patient’s chances of leaving the hospital with good neurological outcome. However hypothermia can be tough, unless you have done a bunch. Learn from my mistakes in this lecture.

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Say It Right

How do you tell someone their loved one died?  Or their loved one is going to die?  Or their loved one is an idiot who tried to steal a bicycle from a mentally challenged individual and got shot in the neck by a “good Samaritan” coming to the aid of the victim?  Does your conversation go something like, “Well, yes, we’d like to arrest the person who did this, but your son is also under arrest.  Yes, I know he got shot, but he was assaulting someone else & trying to steal their bike.  Yes, yes, there’s a bullet sitting an inch away from his spinal cord, I know, but he was in the process of robbing someone else and then he was shot by someone else.  Uh, would you like to see him?”

Since becoming a senior resident, I’ve had to deliver bad news on an almost daily basis.  Today in the middle of a code for a 45 year old in cardiac arrest, I suddenly thought back to my “How to Be a Doctor 101” class, where we sat in front of our colleagues as a professor took us through the “Giving Bad News” scenario.  It usually involved a code situation where you had to come out and tell someone that you “did everything you could,” or  “we used all of our capabilities.”  If you felt it was appropriate you touched the family member on the shoulder, or you patted their hand.  It was all very trite and contrived;  all very John Carter fumbling on “E.R.” and not actually using the words, “they died” giving a patient’s family hope.  We were taught to make sure we said, “… and they died.” We also did the, “I’m sorry, but the test results show that you most likely have cancer” scenario as well.  I’ve had to use that one on several occasions.

Today was hard, though.  We worked on this patient for almost an hour.  We got a pulse back, but did we really get a life back?  Did I bring back a wife and mother to her family, or did I just turn one bad and horrible situation into a worst one?  I don’t know.  What I do know, is that my “How to Be a Doctor 101” class did not prepare me for saying, “Well, she’s not dead, but she was dead, but now she’s got a heartbeat, but I am supporting her on 2 pressors, pressors?, uh, those help keep her blood pressure elevated because her heart’s not working right, well, yes, it’s beating now but it wasn’t beating on it’s own for 45 minutes and we had to do compressions to circulate the blood for her, so she might be brain dead and all her organs may go into failure because she was without oxygen for a long time, well yes, she was getting oxygen through the tube in her mouth into her lungs, but her heart wasn’t beating properly see and we were doing compressions and I have no idea what’s going to happen now, but you should prepare for the worst, or maybe not because we have hypothermia protocols these days and some people do come back, she may or may not, I’m not sure, so, uh, would you like to see her?”

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