ACLS EP Special Considerations Flashcard 3

D. Rationale: Factors associated with 100% mortality after drowning include all of the above EXCEPT for submersion between 5 and 10 minutes. Between 5 and 10 minutes, there is a 56% risk for long-term brain damage or death.

D. Rationale: In pregnancy, hypotension is defined as a systolic BP under 100 mm Hg or under 80% of baseline.

A. Rationale: The clinician should attempt to perform manual left uterine displacement to relieve aortocaval compression. Fetal monitors should be removed to prevent arcing when performing defibrillation. An advanced airway may be required. An experienced provider should perform this task since airway placement may be difficult. If the patient is receiving magnesium, the infusion should be discontinued, and calcium chloride or gluconate should be administered.

C. Rationale: Lightning strikes are rare occurrences that can be fatal. Most injuries occur via absorption of current energy via radial extension from an object on the ground that was directly hit. It is much more rare (< 10% chance) for a person to be hit directly by lightning. Lightning events typically occur outdoors and can be more common in certain regions of the country. Common fatal arrhythmias associated with lightning are ventricular fibrillation and asystole. Unlike manmade electrocution, individuals struck by lightning do not tend to remain conductive to others as they are no longer in touch with the source of current.

B. Rationale: Submersion in icy water can lead to protective hypothermia due to the slowing of metabolic processes and increased tolerance of hypoxia. This is only the case if hypothermia occurs before hypoxia; secondary hypothermia, which occurs following the hypoxic event, is not protective. Unlike cardiac arrest, in which chest compressions are given first, hypoxia associated with drowning is best treated with immediate rescue breathing before chest compressions. Cervical spine injury is quite uncommon in drowning and occurs in less than 0.5%. Situations that should raise the suspicion for cervical spine injury include associated diving, high-speed water crafts, parasailing or hang gliding, water slides, and intoxication. The Heimlich maneuver is not recommended in routine drowning, and it is not effective at removing excess fluid from the lungs. It should only be used if there is a concern for a foreign body in the airway or when there is associated choking.

A. Rationale: As the uterus increases in size, it compresses the inferior vena cava and aorta. This leads to decreased cardiac output and systemic outflow. As a result, chest compressions are impaired due to diminished preload, which reduces perfusion of the heart and brain. Manual displacement of the uterus can help in this situation. Other physiologic changes include laryngeal edema, which can make intubation challenging, and relative respiratory acidosis, which increases the risk of sudden-onset desaturation. There is no associated bronchoconstriction, heart elevation, or respiratory alkalosis during pregnancy.

C. Rationale: Protective hypothermia typically occurs when rapid cooling of the body happens before the hypoxia-associated ischemia of respiratory or cardiac arrest. It typically happens in icy water in which the core body temperature drops rapidly. This can happen when an individual is submerged in icy water such as falling though cracked ice. A patient with an MI in cold weather typically will have ischemia occur before hypothermia, and a patient drowning in cold water will typically have ischemia have respiratory arrest occur before reaching a temperature that would produce protective hypothermia. While individuals found in an avalanche have a body temperature drop of 8–9 degrees per hour, this is typically too slow to achieve hypothermia before asphyxiation from the avalanche burial.

C. Rationale: Decisions to terminate resuscitation are very nuanced and require an evaluation of prognosis, patient and family wishes, and important ethical considerations. However, if there is clear evidence that a patient does not want resuscitation, this should be respected. A “do not resuscitate” bracelet effectively demonstrates this wish. Hypothermic patients should have continued resuscitation efforts as futility cannot be determined until normothermia is achieved. In a pregnant woman with a viable fetus and fatal injury, rapid cesarean section is the goal and may require continued resuscitation efforts to ensure adequate perfusion to the fetus until delivery. Terminal illness does not preclude patients from being treated for something else. If there is an acute and reversible condition leading to arrest, a terminally ill individual can still benefit from resuscitative efforts.

C. Rationale: IV beta-blockers are indicated for multiple emergency situations. They are given as a secondary treatment in symptomatic SVT that have not improved with vagal maneuvers and adenosine. They are also useful in the management of toxin-associated tachycardia. However, they are contraindicated in cocaine overdose due to the concern for cardiac ischemia and hypertension in these patients. IV beta-blockers can be used early in the management of ACS, and some studies show a decrease in death from VF but an increase in death from shock. Oral beta-blockers are given to all patients regardless of perfusion strategy. Beta agonists, not beta-blockers, can be used in severe asthma when the patient cannot use inhaled medications.

A. Rationale: Although all of these interventions are necessary, the first thing the team must do is remove cold, wet clothes to prevent ongoing heat loss.