Special Resuscitation Cases
A multitude of drugs, toxins and circumstances may cause near-arrest or arrest. Hypothermia and hyperthermia, Some toxins, including carbon monoxide can also be included.
Electrical and Lightning Injuries
Arrest may occur from high voltage direct current (> 1000 volts). Do not attempt removal until current is shut off. With low voltage exposure, such as 120 volts of alternating current (AC) from a hair dryer or radio, for example, removal can be accomplished with cloth, rubber or wood. High voltage (DC) contact usually causes asystole; low voltage (AC) usually causes ventricular fibrillation. A lightning strike may carry up to a billion volts of DC energy and may strike directly, obliquely or “splash” from contact as it strikes the ground or at an object and spreads out to involve the victim.
the ABCs are assessed and CPR is begun, followed by intubation and IV access. Defibrillation or treatment for asystole is performed as required.
Although hypokalemia and hyperkalemia may both cause arrest (in hypokalemia the heart stops in systole; in hyperkalemia it stops in diastole), hyperkalemia is the more potentially fatal condition, sometimes seen in the dialysis patient (i.e., K+ level above 8 mEq/L). Less common causes are crush injuries, burns, acidosis and some drugs (i.e., digoxin, ACE-inhibitors). It is often impossible to learn the reason for the arrest other than a fragmentary history (i.e., dialysis).
the ABC’s are assessed and CPR is begun, followed by intubation and IV access. Defibrillation or treatment for asystole is instituted as needed. If the cause is known, 10 cc of a 10% solution of calcium chloride is administered. Calcium stabilizes the cardiac cell membrane, preventing the continued adverse effect of the increased K+. If the resuscitation is successful, glucose 2 amps + regular insulin 10 units IV push
plus bicarb 1 amp will lower the K+ by moving it into the cells, thus decreasing the level in the bloodstream.
The main causes of cardiac arrest in pregnancy are pulmonary embolism, trauma (high homicide), hemorrhage and pre-existing cardiac disease.
the cause is often not known (other than trauma).
Usual therapies such as heparin for pulmonary embolism will probably not be effective. The patient in late pregnancy is turned to the left and a roll or Cardiff wedge is placed under the right flank and hip for CPR. Appropriate therapy for cardiac arrhythmias and blood loss (IV NS and O-neg packed cells) is instituted. If pulmonary embolism seems likely, thrombolytics may be tried. Emergency cesarean section is performed if 5 minutes have elapsed, the fetus is viable (>20 weeks) and therapy has not been successful. The
results are poor if the C-section is delayed for up to 15 minutes.
Teenagers and toddlers are frequently affected. Drugs, alcohol (60% of teenage drownings), cervical spine injury, seizure disorders, mental retardation, child abuse and suicide are contributory. Death/arrest is from laryngospasm and asphyxia. Hypothermia is frequently present.
CPR is begun after removal from the water, with C-spine protection if a head-injury is suspected. On EMS arrival, the ABC’s are assessed (including C-spine immobilization) and CPR continued as needed. Supplemental oxygen by mask is administered to all patients, with fast transport. In the emergency department IV access is secured, and intubation is performed as needed. Appropriate therapy for cardiac arrhythmias is instituted. If hypothermia is present, rewarming measures are begun and resuscitative measures are continued until the temperature is 90˚F.