Critical care

Therapeutic strategies in managing cardiac arrest

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Therapeutic strategies in managing cardiac arrest

  • Updated resuscitation guidelines emphasize the need for minimally interrupted high quality chest compressions as a prerequisite for successful resuscitation outcome.
  • Resuscitation involves the integration of complex systems and the interdisciplinary coordination of multispecialty emergency and critical care providers.
  • The immediate period following return of spontaneous circulation (ROSC) is crucial and is dominated by the presence of two critical goals- identification of pathophysiological cause, and the assessment and initiation of time- dependent interventions, directed at preventing recurrent arrest, and improving immediate and long- term outcome.
  • There is no vasopressor or anti-arrhythmic agent whose use is associated with improved outcome at discharge. In-hospital resuscitation should focus on the provision of high quality chest compressions and the search for immediate treatable precipitants of the arrest in those patients who achieve ROSC.
  • A systematic checklist may aid in the systematic evaluation of patients following ROSC.

Management after resuscitation from cardiac arrest

  • Following return of spontaneous circulation, the quality of the treatment provided in the post-arrest period influences outcome.
  • Most patients resuscitated after a prolonged period of cardiac arrest will develop the post-cardiac arrest syndrome.
  • All survivors of out-of-hospital cardiac arrest should be considered for urgent coronary angiography unless the cause of cardiac arrest was clearly non-cardiac or continued treatment is considered futile.
  • Several interventions may impact on neurological out-come, the most significant of these is targeted temperature management.
  • In patients remaining comatose after resuscitation from cardiac arrest, prediction of the final outcome in the first few days may be unreliable. Prognostication should normally be delayed until at least 3 days after return to normothermia and should involve more than one than one mode (e.g. clinical examination combined with another investigation).

Key components of the post-cardiac arrest syndrome.

  • Post- cardiac arrest brain injury- this manifests as coma and seizures.
  • Post- cardiac-arrest myocardial dysfunction –this can be severe and usually recovers after 48 hours.
  • Systemic ischemia/reperfusion response –tissue reperfusion can cause programmed cell death (apoptosis) effecting all organ systems.
  • Persisting precipitating pathology-coronary artery disease is the commonest precipitating cause after OHCA

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Management of Benzodiazepine Poisoning

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Key points in Critical Care Medicine

                       “Adapted from Oxford Textbook of Critical Care”

Management of Benzodiazepine Poisoning

  • Benzodiazepines are the drugs most frequently involved in acute self-poisoning.
  • Benzodiazepine overdose usually has a good prognosis. Most patients do well with careful observation and prevention of complications. Supportive care including oxygen, intubation, respiratory support, and fluid administration may be required in some cases.
  • Care should be taken with elderly patients, or those with chronic obstructive pulmonary disease or liver disease. Fast- acting agents and ingestion of other central nervous system depressants, including alcohol, may present an additional risk.
  • Early administration of activated charcoal in fully conscious patients who are able to protect their airway is only needed if there are co-ingestants.
  • Flumazenil may help confirm the diagnosis, improve alertness, and prevent the need for respiratory support in some patients, especially after accidental poisoning in children. Contraindications include patients on long-term treatment and/or dependent on benzodiazepines, or those who have simultaneously ingested proconvulsant or prodysrhythmic substances, or at risk of increase intracranial pressure.

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Epidemiology and pathophysiology of Traumatic Brain Injury

Ecccp@scribe Critical care ,

Key points in Critical Care Medicine

                       “Adapted from Oxford Textbook of Critical Care”

Epidemiology and pathophysiology of Traumatic Brain Injury

  • Traumatic brain injury (TBI) is a devastating injury that causes a huge burden of disease around the world; approximately 1.6 million people suffer a TBI in the USA each year.
  • TBI is a bimodal disease that affects young adults (15-34), the elderly (>75), and males more than females.
  • Mechanism of injury, age, gender, and initial severity of injury are the most significant predictors of mortality.
  • Harm from TBI arises from direct damage to the brain at the time of the initial injury (primary injury), which places the brain at risk of further harm secondary injury.
  • Secondary injury may occur due to intracranial hypertension, hypotension, hypoxia, reduced cerebral perfusion, and inflammation.

Assessment of Traumatic Brain Injury

  • Early assessment is based on a careful history, clinical assessment, and neurological imaging-usually a CT scan of the brain.
  • An immediate CT scan of brain should be obtained in any adult patient at risk of harbouring intracranial pathology.
  • In adult patients who have a Glasgow Coma Scale score below 15 and indications for a brain CT scan, the scan should include the cervical spine by scanning from the base of skull to T4.
  • Establishing a reliable prognosis early after injury is notoriously difficult, but recent predictive models are readily accessible to clinicians via a web-based calculator to aid early clinical decision making and to allow better informed discussions with patient’s families.

Management of Traumatic Brain Injury

  • Admission to a centre offering specialist neurological critical care and management of extracranial injuries improves outcome.
  • Initial management priorities address the ‘ABCs’-airway with cervical spine control, breathing, and circulation. Neurological assessment using the Glasgow Coma Score and pupillary reaction should be repeated regularly to detect deterioration.
  • Intracranial haematomas causing mass effect should be surgically evacuated without delay.
  • Specific TBI management focuses on avoiding secondary cerebral insults by avoiding hypotension and hypoxia, controlling ICP, and maintaining cerebral perfusion pressure.

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