A patient presents to the emergency department (ED) with acuteonset chest pain radiating to his jaw and down his left arm. During evaluation he becomes unresponsive and pulseless. His ECG demonstrated wide complex tachycardia.
Which of the following answer choices is most correct regarding the underlying rhythm and coinciding appropriate treatment for this patient?
Correct Answer: E
A successful resuscitation effort is determined by high-quality CPR in addition to timely defibrillation, if amenable. Recognizing the difference between shockable and nonshockable rhythms is key to resuscitation efforts. The patient in this question has pulseless ventricular tachycardia, which should be treated with biphasic unsynchronized cardioversion starting at 120 J. This cardioversion continues during the process of advanced cardiac life support (ACLS) until ROSC occurs or the patient becomes asystolic or develops PEA. If using a monophasic defibrillator, then a single unsynchronized 360-Joule dose should be administered.
A 70-year-old man with history of coronary artery disease has a witnessed cardiac arrest. He undergoes 10 minutes of resuscitation with return of spontaneous circulation (ROSC) but remains comatose.
Which of the following treatments for postresuscitation care is most likely to improve outcome for this patient?
Correct Answer: C
The tenets of postcardiac arrest care include targeted temperature management (TTM), hemodynamic and ventilation optimization, immediate coronary reperfusion with percutaneous coronary intervention (PCI, if amenable), glycemic control, and neurologic care. The 2015 ACLS guidelines recommend that all comatose (ie, lacking meaningful response to verbal commands) adult patients with ROSC after cardiac arrest should undergo TTM, with a target temperature between 32°C and 36°C maintained constantly for at least 24 hours. This recommendation is based on studies of TTM which compared cooling to temperatures between 32°C and 34°C with no well-defined TTM and found improvement in neurologic outcome for those in whom hypothermia was induced. A more recent high-quality study compared temperature management at 36°C and at 33°C and found outcomes to be similar for both. Taken together, the initial studies suggest that TTM is beneficial, so the recommendation remains to select a single target temperature within the 32°C and 36°C range.
There are multiple goals when it comes to hemodynamic and ventilation optimization in postcardiac arrest patients. Based on the 2015 ACLS guidelines, patients should receive the lowest possible FiO2 to maintain an SpO2 of 94% or greater. The patients’ associated comorbidities and current medical problems will ultimately dictate the goal PaCO2 in the postcardiac arrest patient. Permissive hypercapnia may be most appropriate in patients with acute lung injury while maintenance of normocarbia is warranted in patients with cerebral edema. With regards to hemodynamics goals, the ACLS guidelines recommend maintaining a mean arterial pressure of 65 mm Hg or greater. In patients who have suspected coronary artery occlusion as the source of the cardiac arrest, coronary reperfusion is warranted after return of spontaneous circulation.
The 2015 AHA Guidelines do not recommend a specific target range for glucose management in the postcardiac arrest patient. Variability in glucose levels in this patient population is common and often timedependent. Stress-induced hyperglycemia is commonly found in the earlier phase of a postcardiac arrest patient while hypoglycemia is commonly seen during the rewarming process after 24 hours of hypothermia. Despite numerous studies looking at glycemic control in postcardiac arrest patients, the optimal target range still remains unknown. Given the variability of blood glucose levels in these patients, frequent monitoring should be performed to avoid hypoglycemia and hyperglycemia.
A 23-year-old man presents to the ED after being a passenger in a high-speed motor vehicle accident. He was restrained and there was airbag deployment. Upon initial presentation to the ED, he was conversant, oriented, and following commands. However 20 minutes later, he is lethargic, only opening his eyes to painful stimuli, is making incomprehensible sounds, and only withdraws to pain.
What are the initial and subsequent Glasgow Coma Scores (GCS) for this patient?
Correct Answer: A
The GCS (see figure below) is a reliable and objective way of recording the initial and subsequent level of consciousness in a person after a traumatic injury. The scale assesses patients according to three aspects of responsiveness: eye-opening, motor, and verbal responses. The levels of response in the components of the GCS are “scored” from 1, for no response, up to normal values of 4 (eye-opening response), 5 (verbal response), and 6 (motor response). The total Coma Score thus has values between 3 and 15, 3 being the worst and 15 being the highest. The findings in each component of the scale can aggregate into a total GCS, which gives a less detailed description but can provide a useful “shorthand” summary of the overall severity. Based on the question, the patient had a GCS of 15 (4+5+6) at presentation, which later decreased to 8 (2+2+4).
From Teasdale G, Jennett B. Assessment of coma and impaired consciousness. Apractical scale. Lancet. 1974;2(7872):81-84.
A 33-year-old morbidly obese man presents to the ED after being an unrestrained passenger in a high-speed motor vehicle accident. On evaluation, it is noted that he has distended neck veins, difficulty breathing, and hyperresonance to percussion on the right. Breath sounds are difficult to auscultate.
What is the MOST likely diagnosis and appropriate treatment for this patient?
The primary survey is designed to rapidly assess and treat any lifethreatening injuries. Major causes of death in trauma patients are airway obstruction, respiratory failure, shock from hemorrhage, and brain injuries. Specific injuries which are immediately life-threatening include:
The patient’s clinical signs and symptoms are most consistent with TPX which should be treated with immediate decompression. TPX results from the trapping of air within the pleural space which does not have a way to escape. Progressive build-up of pressure in the pleural space pushes the mediastinum to the opposite hemithorax and obstructs venous return to the heart. This leads to circulatory instability and may result in traumatic arrest.
Classic signs of a TPX include deviation of the trachea away from the side with the tension, absent breath sounds, hyperresonance to percussion, deviated trachea, and distended neck veins. However these classic signs may be absent and more commonly the patient is tachycardic and tachypneic, and may be hypoxic.
Treatment of TPX is decompression. This will allow the mediastinum and associated organs to return to their normal positions and relieve the pressure. Whether the initial decompression is with a chest tube versus a needle is dependent on the clinician’s skill set, available equipment, and the urgency of the need for decompression. Of note, a standard 14 gauge angiocatheter cannot penetrate the chest wall and reach the pleural space in up to one-third of trauma patients. A 10-gauge, 7.5 cm (3 inch) armored angiocatheter is able to penetrate the pleural space in most instances. If needle decompression is performed, it should be followed immediately by tube thoracostomy.
Cardiac tamponade is most commonly caused by penetrating injuries, such as gunshot or stab wounds, which cause blood to pool in the fixed, fibrous pericardial sac that leads to decreased venous return to the heart and resultant decreased cardiac output. Cardiac tamponade is a clinical diagnosis based on physical findings of muffled heart sounds, dilated neck veins, and hypotension which is known as “Beck triad.” Cardiac tamponade can lead to Kussmaul sign (increased venous pressure with inspiration) and can progress to pulseless electrical activity. Treatment varies on the patient’s clinical situation, ranging from pericardiocentesis to resuscitative thoracotomy. Differentiating between TPX and cardiac tamponade may be challenging as both can result in hemodynamic compromise or cardiac arrest. Asymmetric absence of breath sounds, hyperresonance to percussion, and tracheal deviation are signs of TPX that are not seen in cardiac tamponade. An ultrasound exam utilizing FAST protocol, if available, can be valuable in diagnosing and differentiating between these conditions.
A 4-year-old girl presents to the ED after being struck by a vehicle while riding her bike. She was awake and complaining of neck pain immediately after the accident but is somnolent with sonorous respirations on your examination in the ED. Her oxygen saturation is 89% and her heart rate (HR) is 50 beats/min. According to the Pediatric Acute Life Support guidelines,
what are the MOST appropriate initial steps in assessment and management for this patient?
Pediatric Advanced Life Support (PALS), similar to both ACLS and advanced trauma life support (ATLS), follows a systematic approach. First Impression followed by evaluate-identify-intervene (which includes primary assessment, secondary assessment, and diagnostic tests) constitutes the steps in the PALS algorithm. The algorithm starts with a first impression to help determine whether or not the patient is in imminent danger, either of cardiac or respiratory failure. Patients who are conscious or unconscious, but breathing can progress to the evaluate-identify-intervene step in the algorithm. Patients who are not breathing adequately but have a pulse greater than 60 beats/min should undergo rescue breathing. Patients with a pulse less than 60 beats/min should undergo CPR.
The second step of the algorithm is evaluate-identify-intervene. This is an ongoing cycle, in which the clinician is repeatedly reevaluating the patient and performing interventions based on the findings. Throughout the process, if the patient stops breathing or has a pulse less than 60 beats/min, then the clinician should begin rescue breathing or CPR, respectively. If the patient remains breathing and has a pulse greater than 60 beats/min, then the clinician should progress to the next steps in the algorithm.
Evaluate-identify-intervene are components of the primary assessment and secondary assessment, and guide the choice of diagnostic testing. The primary assessment follows the primary survey in ATLS: Airway, Breathing, Circulation, Disability, Exposure. An oxygen saturation that is less than 90% indicates that respiratory support is needed. In the pediatric patient population, a heart rate less than 60 beats/min suggests cardiac failure, and CPR should be initiated.
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