The Arrested Patient
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Transcript of The Arrested Patient
1
The arrested patient
Adapted from Lichtenstein's SESAME protocol
(with permission)
2
Summary
1 (Ongoing resus) Clinical assessment: formulate the question
2 Rapid arrest screen
3 Form a working diagnosis
4 Continue resuscitation
5 Re-scan / monitor progress / further investigations
1. Formulate the question
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1. Formulate the question
a. Why is the patient arrested: is there a reversible cause?
b. Have I successfully intubated? (If ETCO2 not recording)
Is there a reversible cause?
Tension PTX
Tamponade
Toxins
Thrombosis (MI)
Thromboembolism (PE)
Hypovolaemia
Hypothermia
Hypoglycaemia
Hyperkalaemia
Hydrogen (acidosis)
Is there a reversible cause?
Tension PTX
Tamponade
Toxins
Thrombosis (MI)
Thromboembolism (PE)
Hypovolaemia
Hypothermia
Hypoglycaemia
Hyperkalaemia
Hydrogen (acidosis)
Successful intubation?
Bilateral pleural sliding = both lungs ventilated
Unilateral sliding = 1 lung ventilation / PTX
No sliding = maybe the ETT is in the oesophagus / NB bilateral PTX?
2. The arrest screen
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Curved probe, abdominal preset
Sagittal axis
Just like FAST!
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A 3-step scan
1. Single view heart
2. Anterior lung fields (1 point each side)
2. At your discretion:• IVC (hypovolaemia)• Abdo (eg AAA / free fluid in trauma)• Or finish scanning
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Don’t get in the way of CPR
You need to scan during the pulse check
You have ten seconds!
CPR
Pulse check & scan lungs
CPR
Pulse check & scan heart
CPR
Pulse check & consider options
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The arrest scan
Step 1
Single view of heart
What am I looking for?
Is there a heartbeat?
Pericardial effusion?
RV > LV?
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Step 1: single view heart
• Using the curved probe, subcostal view is easiest• Probe transverse, marker to patient's right• ID heart (probe angled cephalad)• Options if you can't obtain an adequate view:
• Try different window (apical, parasternal)• Try different probe (phased array)• Get help
Subcostal scan heart
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1
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Big RV
squashing LVIt's a PE
Caveats:• Is it chronic? Thickened RV wall
• Is it dilated? Intra arrest
Action: consider thrombolysisIf in doubt, consider 3-point DVT scan
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2
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Pericardial fluid
It’s a tamponade
Caveat: it might be an incidental finding
What if you’re wrong?
What have you got to lose?
Action: pericardiocentesis
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3
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Active heart, small LV = PEA
Pseudo-EMDHypovolaemia
Action: replace volumeFind & treat cause = go to step 3
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4
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Cardiac standstill
Exclude other reversible causes (Hs, Ts)
Action: cease CPR
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Inadequate view
Options:Try another window
Try cardiac probeGet help
Step 1: single view heart
Big RV
Squashing LV
Pericardial fluid
Cardiac standstill
Inadequate
view
Small volume heart beating
?
Step 1: single view heart
Big RV
Pericardial fluid
Cardiac standstill
Inadequate
view
Pseudo-EMD
PE
Consider
thrombo-lysis
Tamponade
Drainage
Hypovolaemia
IV fluid
Proceed to step 3
R.I.P.
Exclude other reversible
causes
Cease CPR
Keep looking
Get help
Step 1: single view heart
Pseudo-EMD
Hypovolaemia
IV fluid
Proceed to step 2
Step 2
Anterior chest
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Step 2: anterior chest
• Probe sagittal, midclavicular line• Just 1 spot on each side• Ideally the most elevated portion of chest
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TOP TIP: you don’t need to be exact
• If tension PTX, it will fill the hemithorax• You’ll see it anywhere on the anterior chest
Step 2 findings
Neither lung is sliding?
One lung is not sliding?
Both lungs sliding
Step 2 findings
Neither lung is sliding?
One lung is not sliding?
Both lungs ventilating
PTX or1 lung ventilation
Not ventilating!(NB bilateral PTX?)
No PTXLungs are ventilating
Step 2 findings
Neither lung is sliding?
One lung is not sliding?
Both lungs ventilating
PTX or1 lung ventilation
Not ventilating! No PTX
Check the airway Check the ETTIs there a lung Point (PTO)?
Go to step 3
Recall: the lung point
At the edge of a PTX, you can sometimes see normal lung moving
US image: 1 side of image doesn't slide with breathing (= the PTX); the other side shows sliding (= the lung)
This spot is the lung point & is 100% specific to PTX
What if there's no lung point?
Maybe 1 lung ventilation
Maybe a massive PTX (entire lung
collapsed)
What if there's no lung point?
Maybe 1 lung ventilation
Maybe a massive PTX (entire lung
collapsed)
Be a doctor
Go back to clinical picture & urgently drain the PTX or pull back the ETT
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Step 3
Hypovolaemia
What’s the cause?
At your discretion:• Review clinical picture
• Scan the IVC ( confirm hypovolaemia)• Scan the abdomen (eg AAA / free fluid in
trauma)
Recap: the arrest screen
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A 3-step scan
• 1. Anterior lung fields• 2. Single view heart• 3. At your discretion:
• IVC (hypovolaemia)• Abdo (eg AAA / free fluid in trauma)• Or finish scanning
Step 1: single view heart
Big RV
Pericardial fluid
Cardiac standstill
Inadequate
view
Pseudo-EMD
PE
Consider
thrombo-lysis
Tamponade
Drainage
Hypovolaemia
IV fluid
Proceed to step 3
R.I.P.
Cease CPR Keep looking
Get help
Step 2: anterior lungs
Neither lung is sliding?
One lung is not sliding?
Both lungs ventilating
PTX or1 lung ventilation
Not ventilating! No PTX
Check the airway Check the ETTIs there a lung Point (PTO)?
Go to step 2
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Step 3 if hypovolaemia
At your discretion:• Review clinical picture
• Scan the IVC (confirm hypovolaemia)• Scan the abdomen (eg AAA / free fluid in
trauma)
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Watch the video again
45
Further tests?
when resuscitation phase completed
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Arrest screen: summary
1 Don’t get in the way of CPR
2 Ten seconds for each step
3 Make a working diagnosis
4 Re-scan / monitor progress / further investigations