6. Cardiac Arrest
CPR Quality
Push hard, push fast (≥100/min),
complete chest recoil
Depth ≥1/3 of AP diameter
Minimize interruptions in
compressions
Avoid excessive ventilation
Rotate compressor every 2 minutes
If no advance airway 15:2
compression-ventilation ratio
If advance airway 8-10 beats/min with
continuous chest compression
Shock and Drugs
Shock Energy for Defibrillation
First shock 2 J/kg, Second shock 4 J/kg
Subsequent shock ≥4 J/kg, max 10 J/kg or adult dose
Drug therapy
Epinephrine IO/IV dose 0.01 mg/kg (0.1 ml/kg of 1:10,000 concentration)every 3-5 minutes
Epinephrine ET dose 0.1 mg/kg (0.1 ml/kg of 1:1,000 concentration)
Amiodarone IO/IV dose 5 mg/kg bolus during cardiac arrest. May repeat up to 2 times for refractory VF/ pulseless VT
11. Sepsis and Septic Shock
Stage of Sepsis
SIRS >> two or more of the following: BT, HR, RR, WBC
Sepsis: SIRS + suspected or culture - documented infection
Severe sepsis: sepsis + organ dysfunction (ARDS, CVS, others at least 2 organ)
Septic shock: sepsis + cardiovascular organ dysfunction
MODS: dysfunction of 2 or more systems
14. Diabetic Ketoacidosis
Criteria Diagnosis
Serum glucose > 250 mg/dL + Ketone in serum and urine + Acidosis: HCO3 <15 mmol/L or
venous pH <7.3
Severity Assessment Mild Moderate Severe
Plasma glucose (mg/dL) >250 >250 >250
Venous pH 7.20-7.29 7.10-7.19 <7.10
Serum bicarbonate (mmol/L) 10-14.9 5.0-9.9 <5.0
Urine ketone Positive Positive Positive
Serum ketone Positive Positive Positive
Anion gap >10 >12 >12
Alteration of conscious Alert Alert/ drowsy Stupor/ coma
Treatment
Fluid and electrolyte therapy
0.9% NaCl 10-20 ml/kg/ hr for 1-2 hr
2 day maintenance + 7-10% deficit in 48 hr (avoid over 4 L/m2/day)
Add 5% dextrose when BS 250-300 mg/dL
K replacement after voiding
Insulin
Start after initial rehydration 0.1 U/kg/kr
Reduce blood glucose 75-100 mg/dL/hr, maintain blood glucose 150-200 mg/dL
Correct acidosis: 7.5% NaHCO3 infusion when shock or persistent/ severe acidosis after initial fluid
resuscitation (HCO3 <5 mmol/L, pH <6.9)
Monitoring:
Vital signs, blood glucose q 1 hrs.
Electrolyte, blood gas, intake and urine output, urine ketone q 2-4 hrs.
Precipitating factor >> infection, stop insulin, diet
Complication monitoring: hypoglycemia, persistent acidosis, cerebral edema, hypokalemia
15. Acute Renal Failure
Complication in ARF
Metabolic: acidosis, hypocalcaemia, hyperphosphatemia, hyperkalemia, uremia, hyperuricemia,
hypermagnesemia
CVS: arrhythmias, hypervolemia/ hypovolemia, CHF, uremic pericarditis, hypertension
Respiratory: pneumonia, uremic pleuritis, pulmonary edema
GI: hemorrhage, N/V, malnutrition
Neurological: mental status changes and seizure
Hematologic: anemia, coagulopathy
Infectious: catheter-related infection, septicemia, pneumonia, UTI
Treatment
Provide supportive Rx
Stabilize and monitor closely: I/O, BW, electrolyte
Prevent sepsis: limit IV line, remove indwelling urinary catheter, c/s periodically,
administer ATB if indicated
Administer ulcer prophylaxis
Adjust drug according to renal function (usually calculate based on GFR < 10
ml/min/1.73 m2)
Prerenal renal failure
Administer fluid challenge
- Use isotonic solution or 5%D/N/2 then administer 25% of MN fluid in 2 hrs.
- If urine output in 1st 2 hrs. > 2 ml/100 calories indicated prerenal cause
- If urine output < 2 ml/100 calories, administer 10% mannital 5 ml/kg in 1-1.5
hrs. + furosemide 2 mg/kg iv
Inotropic support for CHF
Postrenal failure
Removal of obstruction
Stabilization of electrolyte abnormalities and treatment post-obstructive uropathy
Treatment voiding dysfunction and UTI
16. Intrinsic renal failure
Restrict fluids: insensible loss (25-30% maintenance or 400 ml/m2 as 5-10%D/W) + Urine
output (ml for ml as 0.45% NaCl)
Treatment hyponatremia: maintain serum Na+ 130-135 mmol/L, restrict free water
Dopamine 0.5-4 mcg/kg/min, synergistic effect with furosemide
Metabolic acidosis
Replace base deficit if pH<7.2 or HCO3 <12 mmol/L
Base deficit = 0.3 x BW x (HCO3 desired - HCO3 observed) >> ½ over 2-3 h, rest over next 24 hrs.
Hyperphosphatemia
Calcium carbonate 300-400 mg/kg/day oral
Treatment tetany
Hyperkalemia
Hypertension
17. Seizure
Management
Assessment
• Airway, breathing, circulation, dextrose, fever
Investigation
• Anticonvulsant concentration, CBC, BS, Ca, Mg, kidney and liver function, blood
gas(optional), saved serum for toxicology or virology, emergency neuroimaging studies(for
unknown cause—stable condition)