ACLS for EP. Dr.Suad Al-Abri Emergency Physician & Medical Toxicologist 2 May 2016

Transcription

1 ACLS for EP Dr.Suad Al-Abri Emergency Physician & Medical Toxicologist 2 May 2016

2 Objectives ACLS for Experienced Providers ACLS EP in Toxicology Anaphylaxis Summary

3 ACLS for Experienced Providers

4 ACLS EP When a team leader need to think beyond the guidelines Encourage critical thinking and decisionmaking strategies Help improve outcomes in complex cases Cardiovascular, Respiratory Toxicological emergencies

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7 ACLS EP in Toxicology Use of standard ACLS protocols may not result in optimal care Higher doses of medication Specific therapies is needed Prolong CPR Circulatory assisted devices like ECMO

8 Case 1 A 20-year-old female Found convulsing at home Brought to ED by EMS She was still seizing Then went into cardiac arrest A wide complex rhythm was noted

9 Cardioversion/Defibrillation The same for pulseless patients with drug-induced VT or VF Same for hemodynamically unstable VT with pulses

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11 Sodium Bicarbonate Sodium loading is aimed to overwhelm the sodium channel blockade effect Bicarbonate is aimed to increase ph which in turn Increase protein binding of free TCA and Increase percentage of non-ionized TCA Less binding affinity to cardiac sodium channels.

12 Antiarrhythmics Antiarrhythmics that block the fast sodium channel (eg, sotalol) are contraindicated Phenytoin is no longer recommended for TCA poisoning.

13 Epinephrine Sympathomimetic VF The risk-benefit ratio of epinephrine in management is unknown Increase the interval between doses of epinephrine and Use only standard dosing Avoid high-dose epinephrine.

14 Magnesium Has beneficial effects in certain cases of drug-induced VT May aggravate drug-induced hypotension.

15 Amiodarone A handful of cases of refractory druginduced VT or VF have been reported to respond to amiodarone. Amiodarone should be used with caution because it may worsen druginduced hypotension May have proarrhythmic effects

16 Lidocaine Cocaine-induced myocardial infarction, to prevent 2 nd arrhythmias Consider a lidocaine bolus followed by infusion management of wide-complex tachycardia caused by cocaine Current evidence neither supports nor refutes a role for lidocaine

17 B blockers Propranolol is contraindicated in cocaine overdose It may be useful in the treatment of ephedrine pseudoephedrine and hydrocarbon overdose

18 Lipid Emulsion Therapy Mechanism: unknown Theory: may be due to the migration of amphiphilic (bupivacaine) molecules from binding sites in the heart into the plasmaborn lipid. Evidence: Multiple animal studies (rats, pigs, dogs) show that after circulatory collapse 2/2 bupivacaine toxicity, lipid treatment increased the survival rate from 0% in the control groups to % in the lipid-treated

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20 Prolonged CPR Warrant more prolonged CPR Recovery with good neurologic outcomes has been reported in severely poisoned patients who received prolonged CPR (eg, 3 to 5 hours) with consultation with a poison control center or toxicologist

21 Brain Death Criteria EEG and neurologic exam are invalid Apply only, drug levels are nottoxic. In the presence of toxic drug levels, the only valid confirmatory test for brain death is Absent cerebral blood flow

22 Case 2 30 years old man was admitted with chest infection While getting his first dose of ceftriaxone he went into anaphylaxis His condition deteriorated, Needed intubation, then He went into cardiac arrest

23 Cardiac arrest from anaphylaxis Profound vasodilation Total cardiovascular collapse Tissue hypoxia The challenge is to provide adequate volume replacement were there is increase capillary leak

24 Special Consideration In Anaphylaxis Mointor airway and breathing closely Early intubation if patient develop hoarseness, Lingual edema, oro -pharngeal swelling, severe bronchospasm Have back up plan

25 Management Standard BLS and ACLS Aggressive volume expansion, massive volume needed typically 4-8 liters of isotonic fluid IV antihistamine Steroid

26 Epinephrine Start with IM epinpherine mg, rerpeat every 5-15 min if no clinical improvement If patient is not n cardiac arrest but in anaphylactis shock Iv epinphrine of mg iv Infusion of epinpherine 5-15 mcg/min

27 Summary Critical thinking behind guidelines Think toxins when you have refractory VT/VF Prolong CPR in drug induced arrest Brain death criteria is different Anaphylaxis, early recognition and epinephrine

28 KEEP CALM AND ASK A TOXICOLOGIST