20 TABLE 20–9 (Continued) Determination Derivation Normal O 2 consumption (Ca O 2 − Cv O 2 ) × CO x 10 180–280 mL/min Qs/Qt (shunt fraction) (Cc O 2 − Cv O 2 ) × CO x 10 0.05 (Cc O 2 − Cv O 2 ) ICP Measured 0–20 mmHg CPP MAP − ICP keep >70 mmHg Abbreviations: RAP = right atrial pressures; CVP = central venous pressure; R VP = right ventricular pressure; PAS = pulmonar y artery systolic; PAD = pulmonary artery diastolic; PCWP = pulmonary capillar y wedge pressure; CO = cardiac output; CI = cadiac input; MAP = mean arterial pressu re; MPAP = mean pul- monary artery pressure; SVR = systemic vascular resistance; PVR = pulmonary vascular resistance; ICP = intracranial pressure; CPP = cerebral perfusion pres- sure; BSA = body surface area; DBP = diastolic blood pressure; SBP = systolic blood pressure; Fi O 2 = inhaled O 2 ; Hgb = hemoglobin; Sa O 2 = arterial oxygen, Sv O 2 = mixed venous oxygen saturation; Qs = volume of shunted blood (ie, blood shunted past nonventilated alveoli, not participating in gas exchange); Qt = total cardiac output; C CO 2 = O 2 content of alveolar-capillary blood; C VO 2 = mixed venous O 2 content of pulmonary artery blood. 438 TABLE 20–10 Guidelines for Adult Critical Care Drug Infusions* (Final Concentration) Drug Dilution Flow Rate = mL/h Usual Dose Range Amrinone 500 mg (2 mg/mL) (Inocor) 250 mL 1500 µg/min = 45 LD = 0.75 µg/kg 1000 µg/min = 30 MD = 5–20 µg/kg/min (150 mL PSS+ 750 µg/min = 22.5 100 mL drug) 500 µg/min = 15 PSS only 350 µg/min = 10.5 Diltiazem (Cardizem) 125 mg (1 mg/mL) Bolus = 0.25 mg/kg 125 mL 5 mg/h = 5 over 2 min; may give 10 mg/h = 10 second bolus 0.35 mg/kg 15 min after initial bolus (100 mL diluent 15 mg/h = 15 +25 mL drug) MD = 5–15 mg/h D 5 W or PSS Dobutamine 500 mg (2000 µg/mL) 2.5–20 µg/kg/min (Dobutrex) 250 mL 1500 µg/min = 45 20 (continued ) 439 20 TABLE 20–10 Continued (Final Concentration) Drug Dilution Flow Rate = mL/h Usual Dose Range Dobutamine 1250 µg/min = 37.5 (continued) D 5 W or PSS 1000 µg/min = 30 750 µg/min = 22.5 500 µg/min = 15 250 µg/min = 7.5 Dopamine 400 mg (1600 µg/mL) 0.5–2.0 µg/kg/min (renal) 250 mL 1400 µg/min = 52.5 2.0–10 µg/kg/min (inotropic) 1200 µg/min = 45 10–20 µg/kg/min (vasopressor) D 5 W or PSS 1000 µg/min = 37.5 800 µg/min = 30 600 µg/min = 22.5 400 µg/min = 15 200 µg/min = 7.5 Epinephrine 3 mg (12 µg/mL) Initially 1 µg/min 250 mL 4 µg/min = 20 3 µg/min = 15 Titrate to response D 5 W or PSS 2 µg/min = 10 1 µg/min = 5 Esmolol 5000 mg (10 mg/mL) LD = 500 µ/kg/min over 1 minute (Brevibloc) 500 mL 5000 µg/min = 30 MD = 50 µ/kg/min, titrate to 4000 µg/min = 24 response. D 5 W or PSS 3000 µg/min = 18 Increase by 50 µ/kg/min increments every 5 minutes (continued ) 440 20 TABLE 20–10 (Continued) (Final Concentration) Drug Dilution Flow Rate = mL/h Usual Dose Range Isoproterenol 2 mg (8 µg/mL) Initially: 1–4 µg/min (Isuprel) 500 mL 10 µg/min = 75 6 µg/min = 45 Titrate up to 20 µg/min D 5 W or PSS 4 µg/min = 30 2 µg/min = 15 1 µg/min = 7.5 Labetalol 200 mg (1 mg/mL) Bolus = 20 mg over 2 min (Trandate) 200 mL Additional 20–80 mg may be given (160 mL diluent every 10 min until response or +40 mL drug) 2 mg/min = 120 maximum of 300 mg or Initially 2 mg/min D 5 W or PSS Titrate to response Lidocaine 2 g (8 mg/mL) LD = 1–1.5 mg/kg over 2 min (Xylocaine) 250 mL 4 mg/min = 30 MD = 1–4 mg/min 3 mg/min = 22.5 Maximum 4 mg/min D 5 W or PSS 2 mg/min = 15 1 mg/min = 7.5 Nicardipine 25 mg (0.1 mg/mL) Initially: 5 mg/h (Cardene) 250 mL 5 mg/h = 50 Titrate to BP: increase rate by 2.5 mg/h 7.5 mg/h = 75 every 5–15 min (continued ) 441 20 TABLE 20–10 (Continued) (Final Concentration) Drug Dilution Flow Rate = mL/h Usual Dose Range Nicardipine D 5 W or PSS 10 mg/h = 100 Maximum: 15 mg/h (continued) 12.5 mg/h = 125 MD 3 mg/h 15 mg/h = 150 Nitroglycerin 100 mg (400 µg/mL) Initially 5–10 µg/min (Tridil) 250 mL 80 µg/min = 12 Titrate up by 10–20 µg/min every 5 min D 5 W or PSS 60 µg/min = 9 based on current dose and patient (glass bottle) 40 µg/min = 6 condition 20 µg/min = 3 10 µg/min = 1.5 Nitroprusside 100 mg (400 µg/mL) Initially: 0.3–0.5 µg/kg/min (Nipride) 250 mL 300 µg/min = 45 200 µg/min = 30 Titrate to response every few minutes D 5 W 150 µg/min = 22.5 Maximum: 10 µg/kg/min 100 µg/min = 15 70 µg/min = 10.5 50 µg/min = 7.5 Norepinephrine 4 mg (16 µg/mL) Initially: 8–12 µg/min (Levophed) 250 mL 12 µg/min = 45 8 µg/min = 30 Titrate to response D 5 W or PSS 6 µg/min = 22.5 4 µg/min = 15 2 µg/min = 7.5 (continued ) 442 20 TABLE 20–10 (Continued) (Final Concentration) Drug Dilution Flow Rate = mL/h Usual Dose Range Phenylephrine 50 mg (200 µg/mL) Initially: 10–50 µg/min (Neo-Synephrine) 250 mL 100 µg/min = 30 80 µg/min = 24 D 5 W or PSS 60 µg/min = 18 Titrate to response 50 µg/min = 15 Procainamide 2 g (8 mg/mL) LD = 17 mg/kg over 1 h, or 100 mg (Procan) 250 mL 4 mg/min = 30 every 5 min up to 1 g 3 mg/min = 22.5 MD = 1–4 mg/min D 5 W or PSS 2 mg/min = 15 1 mg/min = 7.5 Vasopressin 100 units (0.4 units/mL) 0.1–0.4 units/min (Pitressin) 250 mL 0.4 units/min = 60 0.3 units/min = 45 Maximum 0.9 units/min D 5 W or PSS 0.2 units/min = 30 0.1 units/min = 15 Abbreviation: LD = loading dose; MD = maintenance dose; BP = blood pressure; PSS = physiologic saline solution; D 5 W = dextrose 5% in water *These agents must be administered in the appropriately monitored clinical setting. Source: Reprinted, with permission, from Thomas Jefferson University Phar macy and Therapeutic Committee, Philadelphia, P A. 443 This page intentionally left blank. CARDIOPULMONARY RESUSCITATION Emergency cardiac care guidelines from the American Heart Association now recommend that health care providers have the following items readily available: gloves, a barrier device or bag mask, and an automated defibrillator to handle cardiac emergencies. In cardiopul- monary resuscitation, remember there are now two sets of ABCDs: Primary Survey • Airway: Assess and manage noninvasively. • Breathing: Use positive pressure ventilations. • Circulation: Perform chest compressions as needed. • Defibrillation: Assess for VT/VF and defibrillate using an AED. These are also called PADs and are becoming widely available in public areas such as airports, sta- diums, health clubs, and shopping malls. Secondary Survey: Uses advanced medical techniques • Airway: Assess and manage with airway device (eg, endotracheal intubation, etc). • Breathing: Verify tube function and placement, use positive pressure ventilation sys- tem through tube. • Circulation: Start IV, attach ECG, use rhythm-based ACLS medications. • Differential Diagnosis: Search for, find, and treat problems according to AHA algo- rithms presented in this chapter. Adult CPR (Victim’s age ≥8 y) One Rescuer 1. Determine unresponsiveness (shake and shout). If the patient is unresponsive, call for help (activate EMS system, eg, call “code,” dial 911). In trauma situation do not move 21 445 21 EMERGENCIES Cardiopulmonary Resuscitation Advanced Cardiac Life Support and Emergency Cardiac Care* Advanced Cardiac Life Support Drugs Electrical Defibrillation and Cardioversion Other Common Emergencies * The section on basis CPR and ACLS are based on guidelines from the American Heart Association and the International Liaison Committee on Resuscitation [Circulation 2000;102 (Sup 1)] and the Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care by the American Heart Assocation in Collaboration with the International Liaison Committee on Resuscitation (ILCOR). Copyright 2002 The McGraw-Hill Companies, Inc. Click Here for Terms of Use the victim unless in immediate danger. Roll victim on to back as a unit if lying face down. Protect the neck. 2. Kneel at the level of the victim’s shoulder. Open the airway (head-tilt, chin-lift,), deter- mine breathlessness (“look [chest movement], listen [for air escaping], feel [for air movement]”) for no more than 10 s. In the unresponsive victim with spontaneous respi- ration, place the victim in the recovery position. Jaw thrust maneuver recommended as alternative for health care providers especially if neck injury is suspected. If the victim is breathing, place in the RECOVERY POSITION (see page 449). 3. If not breathing, give patient two slow ventilations (2 s/inspiration) while maintaining airway. Use pocket mask or bag mask. Volume should be between 0.8–1.2 L. A barrier device (face shield or mask with one-way valve) is recommended if mouth-to-mouth or mouth-to-nose contact is necessary. Ventilate 10–12 breaths/min. If unable to ventilate, reposition head and try again. If unsuccessful, perform the FOREIGN BODY OB- STRUCTION AIRWAY SEQUENCE (see page 448). 4. Check for circulation (breathing, coughing, movement). Palpate the carotid artery no more than 10 s to determine lack of a pulse. If pulse is present, perform rescue breath- ing: 1 ventilation every 5 s (10–12 ventilation/min). 5. If no pulse, use four cycles of 15 compressions and two ventilations (compression rate 100/min, two ventilations 1.5–2 s each). Depth of compression 1.5–2 in. or slightly greater to generate carotid pulse. Apply compressions to lower half of sternum using the heels of both hands placed on top of each other. 6. After the four cycles (approximately 1 min of CPR), pause and check for return pulse and spontaneous respirations. 7. If no pulse or respiration, resume cycles with two ventilations, then compressions, as noted earlier. 8. Incorporate appropriate ACLS management guidelines. Two-Rescuer Adult CPR For laypersons 1. Second rescuer identifies him or herself. Verify that EMS has been notified. If so, sec- ond rescuer gets into position opposite first rescuer. If EMS not notified, the second rescuer does so before assisting first rescuer. 2. First rescuer continues CPR. 3. If and when first rescuer tires, second rescuer takes over one-person CPR as described in the preceding section. For health care professionals 1. Sequence to continue from one-rescuer CPR as mentioned in previous section. Second rescuer identifies him or herself and gets into position for compressions. 2. First rescuer completes compression and ventilation cycle (15 compression and two ventilations). 3. First rescuer then checks for spontaneous pulse and breathing, states: “No pulse con- tinue CPR,” then ventilate once (1.5–2 s). 4. Second rescuer resumes compressions at same rate of 80–100/min.(“1 & 2 & 3 & 4 & 5 & pause,” ventilate) Ratio of five compressions to one breath. If airway is protected, do not pause for ventilations. 5. When ready to switch, rescuer doing compressions says “switch & 2 & 3 & 4 & 5 &.” 6. Both rescuers change position simultaneously immediately after ventilation. 7. Rescuer who will perform ventilations opens airway and performs a 5-s pulse check. 8. If no pulse, give ventilation. Rescuer states “No pulse continue CPR.” 446 Clinician’s Pocket Reference, 9th Edition 21 9. In patient with unprotected airway, cricoid pressure may be applied (Sellick’s maneu- ver) by a third rescuer (if health care professional) to help limit gastric distention. Child CPR (Victim’s age 1–8 y) 1. Determine unresponsiveness, and shout for help. Activate EMS system (call code or 911). 2. Open airway (head-tilt, chin-lift; jaw thrust if neck trauma is suspected), determine breathlessness (follow “look, listen, feel” rubric as for adult). If victim is breathing, place in RECOVERY POSITION (see page 449). 3. If victim not breathing, give two ventilations (1–1.5 s). If unable to ventilate, perform the FOREIGN BODY OBSTRUCTED AIRWAY SEQUENCE (see page 448). 4. Check for circulation (breathing, coughing, movement). Palpate the carotid artery for no more than 10 s to determine presence of a pulse. If pulse is present, perform rescue breathing using pocket mask or bag-mask device (20 breaths/min). 5. If no pulse, or if pulse is <60 bpm and perfusion is poor, begin cardiac compressions at five compressions to one ventilation at rate of 100/min. Depth of compressions less than for an adult (1–1.5 in. or one third to one half the depth of chest).Use the heel of one hand at the lower half of the sternum. Pause compressions for ventilations until pa- tient is intubated. 6. Check for return of pulse and spontaneous breathing after 20 cycles (approximately 1 min). 7. Resume cycles with one ventilation (1–1.5 s each), then resume compressions. Infant CPR (Victim’s age, ≤1 y) 1. Determine unresponsiveness, and shout for help. Activate EMS system (call code or 911). 2. Open airway (head-tilt, chin-lift). Do not hyperextend head; however, create adequate head-tilt to accomplish chest rise with breath. If neck trauma suspected, use jaw thrust. If victim is breathing, place in the RECOVERY POSITION (see page 449). 3. If patient is not breathing, give two ventilations (1–1.5 s) using pocket mask or bag- mask device. If unable to ventilate, perform the FOREIGN BODY OBSTRUCTED AIRWAY SEQUENCE using back blows and chest thrusts as noted on page 448. 4. Check for circulation (breathing, coughing, movement). Palpate the femoral or brachial artery for no more than 10 s to determine presence of a pulse. If pulse is present, con- tinue rescue breathing (20 breaths/min). 5. If no pulse or if pulse is <60 bpm and perfusion is poor, begin cardiac compressions. Draw an imaginary line between the nipples and identify where this line crosses the sternum (intermammary line). The site of compression is one finger breadth below this intersection. Use a compression depth of ¹₂ –1 in., using the middle and ring fingers. Use five compressions to one ventilation (rate of compression is 100/min or 120 min for newborns). 6. Use the mnemonic: (“1 & 2 & 3 & 4 & 5 & pause, head-tilt, chin-lift, ventilate− continue compressions”). When patient is intubated, no need to pause. 7. Check for return of pulse and spontaneous breathing after 20 cycles (1 min). Neonatal CPR 1. The newborn should be dried, placed head down, gently suctioned and stimulated. 2. Supplemental oxygen is useful. If baby is not breathing, ventilate 40–60 breaths/min with gentle puff of air or with bag mask. 21 Emergencies 447 21 [...]... Anticholinergic Crisis Usually related to drug overdose Patients present “red as a beet, mad as a hatter, hot as a furnace, dry as a bone, blind as a bat.” 21 470 Clinician’s Pocket Reference, 9th Edition Physostigmine DOSAGE: 0.5–2.0 mg IV NOTE: Administer S-L-O-W-L-Y (may cause seizures if given rapidly) Have cardiac monitor attached and resuscitation equipment at the bedside Coma 1 2 3 4 5 Establish/secure airway... response in supraven- 21 462 Clinician’s Pocket Reference, 9th Edition tricular tachyarrhythmias Antihypertensive for hemorrhagic and ischemic stroke Do NOT administer along with calcium channel blockers due to risk of hypotension • Metoprolol (Lopressor) SUPPLIED: DOSAGE: 1 mg/mL in 5-mL vial Adults 5 mg slow IV q 5 min, total 15 mg • Atenolol (Tenormin) SUPPLIED: 0.5 mg/mL in 10-mL amp Adults 5 mg... dose, 1 time only • Patients with non-VF/VT rhythms: — Epinephrine 1 mg IV, every 3 to 5 minutes • Consider: buffers, antiarrhythmics, pacing • Search for and correct reversible causes Consider causes that are potentially reversible • Hypovolemia • Hypoxia • Hydrogen ion — acidosis • Hyper-/hypokalemia, other metabolic • Hypothermia 21 Non-VF/VT 4 CPR up to 3 minutes 7 • “Tablets” (drug OD, accidents)... mg/mL in 5- and 10-mL vials DOSAGE: Adults 0.2 mg IV over 15 s then 0.3 mg IV over 30 s, if no response, give third dose Third dose: 0.5 mg IV given over 30 s, repeat once per min until response, or total of 3 mg Furosemide (Lasix) INDICATIONS: Acute pulmonary edema in BP >90–100 Hypertensive emergencies or increased intracranial pressure SUPPLIED: 10 mg/mL in 2-, 4-, and 10-mL amp or vials 21 464 Clinician’s. .. with rapid rate in WPW SUPPLIED: 100 mg/mL in 10-mL vial, 500 mg/mL in 2-mL vial DOSAGE: Adults Recurrent VF/VT: 20 mg/min IV (max total 17 mg/kg) In urgent situations up to 50 mg/min to a total dose of 17 mg/kg Other indications: 20 mg/min IV until one of the following occurs: arrhythmia suppression, hypotension, QRS widens by more than 50%, total dose of 17 mg/kg is given Maintenance: 1–4 mg/min Sodium... access–monitor–fluids • Vital signs, pulse oximeter, monitor BP • Obtain and review 12-lead ECG • Obtain and review portable chest x-ray • Problem-focused history • Problem-focused physical examination • Consider causes (differential diagnoses) 1,2 Serious signs or symptoms? Due to the bradycardia? No Type II second-degree AV block or Third-degree AV block? No Observe Yes 6 3,4,5 Intervention sequence • Atropine... specified): Acetaminophen N-acetylcysteine, 140 mg/kg Anticholinesterases Atropine 0.5–2 mg IV; may need up to (organophosphates, physostigmine) 5 mg IV q 15 min if severe, then 70 mg/kg × 17 more doses; 0.05 mg/kg IV in children Benzodiazepines Flumazenil (see page 463) Beta-blockers Glucagon 0.05 mg/kg IV bolus for BP 90% of patients... therapy • Aspirin • Heparin (if using fibrin-specific lytics) • ␤-Blockers • Nitrates as indicated 3 ST-segment depression/ dynamic T-wave inversion: strongly suspicious for ischemia • ST depression >1 mm • Marked symmetrical T-wave inversion in multiple precordial leads • Dynamic ST-T changes with pain High-risk subgroup with increased mortality: • Persistent symptoms, recurrent ischemia • Diffuse or widespread... block; BBB = bundle branch block; AMI = acute myocardial infarction; MI = myocardial infarction; LV = left ventricle; CK-MB+ = positive for myocardial muscle creatine kinase isoenzyme (Reproduced, with permission, from: Circulation 2000;102 supplement 1, part 6.) 21 460 Clinician’s Pocket Reference, 9th Edition Clinical signs: Shock, hypoperfusion, congestive heart failure, acute pulmonary edema Most likely . maintaining airway. Use pocket mask or bag mask. Volume should be between 0.8–1.2 L. A barrier device (face shield or mask with one-way valve) is recommended if mouth-to-mouth or mouth-to-nose contact. ventilation. 7. Rescuer who will perform ventilations opens airway and performs a 5-s pulse check. 8. If no pulse, give ventilation. Rescuer states “No pulse continue CPR.” 446 Clinician’s Pocket Reference, . AV = atrioventricular. (Reproduced, with permission, from: Circu- lation 2000;102 supplement 1, part 6.) 456 Clinician’s Pocket Reference, 9th Edition 21 DC cardioversion or Amiodarone Evaluate