European Resuscitation Council Guidelines for Resuscitation 2010 ...

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1402 J. Soar et al. / Resuscitation 81 (2010) 1400–1433 • Use multiple shifting agents (see above). • Use removal strategies. • Prompt specialist referral is essential. Patient in cardiac arrest. Modifications to BLS There are no modifications to basic life support in the presence of electrolyte abnormalities. Modifications to ALS • Follow the universal algorithm. Hyperkalaemia can be confirmed rapidly using a blood gas analyser if available. Protect the heart first: give 10 ml 10% calcium chloride IV by rapid bolus injection. • Shift potassium into cells: ◦ Glucose/insulin: 10 units short-acting insulin and 25 g glucose IV by rapid injection. ◦ Sodium bicarbonate: 50 mmol IV by rapid injection (if severe acidosis or renal failure). • Remove potassium from body: dialysis: consider this for cardiac arrest induced by hyperkalaemia that is resistant to medical treatment. Several dialysis modes have been used safely and effectively in cardiac arrest, but this may only be available in specialist centres. Indications for dialysis Haemodialysis (HD) is the most effective method for removal of potassium from the body. The principle mechanism of action is the diffusion of potassium ions across the membrane down the potassium ion gradient. The typical decline in serum potassium is 1 mmol l −1 in the first 60 min, followed by 1 mmol l −1 over the next 2 h. The efficacy of HD in decreasing serum potassium concentration can be improved by performing dialysis with a low potassium concentration in the dialysate, 9 a high blood flow rate 10 or a high dialysate bicarbonate concentration. 11 Consider haemodialysis early for hyperkalaemia associated with established renal failure, oliguric acute kidney injury (
J. Soar et al. / Resuscitation 81 (2010) 1400–1433 1403 Table 8.1 Calcium and magnesium disorders with associated clinical presentation, ECG manifestations and recommended treatment. Disorder Causes Presentation ECG Treatment Hypercalcaemia [Calcium] > 2.6 mmol l −1 Primary or tertiary Confusion Short QT interval Fluid replacement IV hyperparathyroidism Malignancy Weakness Prolonged QRS Interval Furosemide 1 mg kg −1 IV Sarcoidosis Abdominal pain Flat T waves Hydrocortisone 200–300 mg IV Drugs Hypotension AV-block Pamidronate 30–90 mg IV Arrhythmias Cardiac arrest Treat underlying cause Cardiac arrest Hypocalcaemia Chronic renal failure Paraesthesia Prolonged QT interval Calcium chloride 10% 10–40 ml [Calcium] < 2.1 mmol l −1 Acute pancreatitis Tetany T wave inversion Magnesium sulphate 50% 4–8 mmol (if necessary) Calcium channel blocker Seizures Heart block overdose Toxic shock syndrome AV-block Cardiac arrest Rhabdomyolysis Cardiac arrest Tumour lysis syndrome Hypermagnesaemia Renal failure Confusion Prolonged PR and QT [Magnesium] > 1.1 mmol l −1 intervals Consider treatment when [Magnesium] > 1.75 mmol l −1 GI loss Tremor Prolonged PR and QT Iatrogenic Weakness T wave peaking Respiratory depression AV-block Calcium chloride 10% 5–10 ml repeated if necessary AV-block Cardiac arrest Ventilatory support if necessary Cardiac arrest Saline diuresis – 0.9% saline with furosemide 1 mg kg −1 IV Haemodialysis Hypomagnesaemia Severe or symptomatic: [Magnesium] < 0.6 mmol l −1 Intervals Polyuria Ataxia ST-segment depression 2 g 50% magnesium sulphate (4 ml; 8 mmol) IV over 15 min. Starvation Nystagmus T-wave inversion Torsade de pointes: Alcoholism Seizures Flattened P waves 2 g 50% magnesium sulphate (4 ml; 8 mmol) IV over 1–2 min. Malabsorption Arrhythmias – torsade de pointes Increased QRS duration Seizure: Cardiac arrest Torsade de pointes 2 g 50% magnesium sulphate (4 ml; 8 mmol) IV over 10 min. Calcium and magnesium disorders The recognition and management of calcium and magnesium disorders is summarised in Table 8.1. Summary Electrolyte abnormalities are among the most common causes of cardiac arrhythmias. Of all the electrolyte abnormalities, hyperkalaemia is most rapidly fatal. A high degree of clinical suspicion and aggressive treatment of underlying electrolyte abnormalities can prevent many patients from progressing to cardiac arrest. 8b. Poisoning General considerations Poisoning rarely causes cardiac arrest, but is a leading cause of death in victims younger than 40 years of age. 22 Evidence for treatment consists primarily of small case-series, animal studies and case reports. Poisoning by therapeutic or recreational drugs and by household products are the main reasons for hospital admission and poison centre calls. Inappropriate drug dosing, drug interactions and other medication errors can also cause harm. Accidental poisoning is commonest in children. Homicidal poisoning is uncommon. Industrial accidents, warfare or terrorism can also cause exposure to harmful substances. Prevention of cardiac arrest Assess using the ABCDE (Airway, Breathing, Circulation, Disability, Exposure) approach. Airway obstruction and respiratory arrest secondary to a decreased conscious level is a common cause of death after self-poisoning. 23 Pulmonary aspiration of gastric contents can occur after poisoning with central nervous system depressants. Early tracheal intubation of unconscious patients by a trained person decreases the risk of aspiration. Drug-induced hypotension usually responds to fluid infusion, but occasionally vasopressor support (e.g., noradrenaline infusion) is required. A long period of coma in a single position can cause pressure sores and rhabdomyolysis. Measure electrolytes (particularly potassium), blood glucose and arterial blood gases. Monitor temperature because thermoregulation is impaired. Both hypothermia and hyperthermia (hyperpyrexia) can occur after overdose of some drugs. Retain samples of blood and urine for analysis. Patients with severe poisoning should be cared for in a critical-care setting. Interventions such as decontamination, enhanced elimination and antidotes may be indicated and are usually second line interventions. 24 Alcohol excess is often associated with selfpoisoning. Modifications to BLS/ALS • Have a high index of personal safety where there is a suspicious cause or unexpected cardiac arrest. This is especially so when more than one casualty collapses simultaneously.
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