ACLS EP Special Considerations Flashcard 1

C. Rationale: This patient potentially has significant internal bleeding from his multiple traumatic injuries. Cardiac arrest is most likely due to hypovolemia from the blood loss. As this is an extracardiac problem leading to hypovolemia, he most likely will have PEA. PEA is a common finding in hypoxia and hypovolemia, which are highly treatable causes of cardiac arrest. The patient will need volume resuscitation and management of any ongoing sources of bleeding. It is less likely that a young (presumably) healthy individual would have any another cardiac arrest arrhythmia with such a significant cause (hypovolemia) for the arrest.

C. Rationale: The first step in managing a manmade electrical current injury is disconnecting the patient form the source of the current. This is critical as the patient can conduct electrical energy and cause electrocution to rescuers. Most workplaces have protocols available to accomplish this goal, and only trained professionals should attempt to disconnect the injured person. While CPR, defibrillation, and spinal precautions may all be needed for this patient, assessment and treatment will have to wait until the safety of all others can be assured.

C. Rationale: The patient has a sudden cardiac arrest following a sudden blunt injury to the chest. He has a shockable rhythm on cardiac evaluation, which is most likely ventricular fibrillation. This is likely a case of commotio cordis due to a blunt injury during cardiac repolarization. This acute trauma can lead to sudden VF. Acute MI is unlikely in a healthy 23-year-old male. Cardiac tamponade may be traumatic, but it is unlikely to lead to a shockable rhythm. Rather, ECG findings may mimic acute MI with ST changes, especially when associated with pericarditis. Tension pneumothorax may be spontaneous or associated with significant chest trauma. Spontaneous pneumothorax is unlikely to cause such severe clinical symptoms, and even in the case of chest trauma, there is unlikely to be associated VF.

C. Rationale: In a pregnant woman with the uterine fundus above the umbilicus, the pregnancy is likely causing compression of the inferior vena cava and aorta, limiting the effectiveness of resuscitation. If appropriate resuscitation is provided and the patient does not improve, emergency cesarean section is the next step. The goal is to deliver the baby within 5 minutes following maternal arrest. Consequently, after 4 minutes of ineffective resuscitation, cesarean section delivery should take place. Manual displacement of the uterus to the left and up should be done immediately to help relieve compression and improve venous return and cardiac output. Responders should not wait until 4 minutes of ineffective CPR to make this change. Oxytocin causes uterine contractions and is used to induce labor as well as limit post-partum hemorrhage from poor uterine contractions. It is not indicated for failed resuscitation in the woman who is not hemorrhaging. Additionally, induction of labor is not appropriate for a pregnant woman in cardiac arrest, while an emergency cesarean section is. Sodium bicarbonate is not routinely used in pregnancy. While the pregnant woman is less able to sustain acid-base changes, sodium bicarbonate can help to buffer the maternal pH but not the fetal pH and can obscure fetal acidosis.

B. Rationale: The clinician should continue resuscitation efforts (including warming) if the patient’s body temperature is < 30°C.

B. Rationale: These findings would be indicative of a partial response to treatment. In a full response, the PEF/FEV1 would be above 70%. In an inadequate response, the PEF/FEV1 will be under 40%, with minimal improvement after 4 hours. No response would be indicated by a PEF/FEV1 under 25%.

C. Rationale: An ECG finding of PEA at ED arrival is associated with a 100% risk of mortality. The length of submersion is the main prognostic factor for survival following drowning. Submersion over 25 minutes is associated with 100% mortality, while 15 minutes of submersion is associated with closer to an 88% risk of death. Similarly, a longer time for resuscitation indicates poor outcomes, and over 25 minutes is associated with 100% mortality. Cardiac arrest upon rescue from the water is associated with a 93% risk of mortality, while respiratory arrest at the same time is associated with a 44% risk of mortality.

A. Rationale: Surgical procedures, increased or decreased oral intake, respiratory failure, and shock are all acute conditions associated with electrolyte imbalances. The others listed are all chronic conditions.

B. Rationale: Commotio cordis leading to VF can be incited by a significant force to the chest during repolarization in the cardiac cycle. This may be the mechanism of arrhythmia following significant blunt trauma, including that caused by a baseball or other small object.

C. Rationale: Research shows that, when buried by snow, an individual’s body temperature decreases by 8–9°C per hour.