Page 696 - ACCCN's Critical Care Nursing

Resuscitation 673

Case study, Continued
(PEEP) and pressure support was initiated. However, Thomas hypothermia/hyperthermia, tension pneumothorax, tamponade,
became increasingly anxious, frightened, trying to get off the ED toxins, thrombosis.
trolley and continually attempting to remove the mask.
After every second loop of CPR Thomas was given 1 mg of IV
At this stage Thomas had an altered conscious state, was adrenaline. Each cycle equated to 2 minutes of CPR (5 sets of 30
exhausted, tachycardic, tachypnoeic and hypoxic. It was evident com pressions and 2 breaths). Compressions continued during all
that Thomas was failing and was in need of sedation, paralysis, interventions in order to minimise interruptions to CPR.
intubation and mechanical ventilation. There was some discus- During the simultaneous ALS interventions, it became evident that
sion regarding the extent of Thomas’ disability issues and Thomas was ventilating only one lung, his trachea was displaced
whether intubation and ventilation was suitable. It was decided to the right and lung sounds were absent from the left chest. In
that in the absence of an advance directive or ‘do not resuscitate’ view of his acute asthma attack and subsequent mechanical ven-
(DNR) order that a continuation of resuscitation was appropriate tilation it was clear that Thomas was suffering a tension pneumo-
and proper. thorax that resulted in PEA and cardiopulmonary arrest. An urgent

The decision to intubate was made, consent was gained from chest X-ray was ordered, but in the meantime a 16 gauge IV
his mother and Thomas was sedated and paralysed and intu- cannula was inserted in the second intercostal space on the left
bated with a size 8 mm endotracheal tube (ETT). Following his side of the anterior chest. Thomas’ chest was decompressed and
intubation Thomas was ventilated on pressure control (SIMV an underwater seal chest drain was set up to be inserted. This inser-
mode) with a rate of 28 and an inspiratory/expiratory (I : E) ratio tion resulted in Thomas’ tension pneumothorax being successfully
of 1 : 4. During insertion of an arterial line Thomas was noted resolved.
to be pulseless with a sinus rhythm on the monitor. A diagnosis Four minutes into the arrest, return of spontaneous circulation was
of pulseless electrical activity (PEA) was made and CPR was achieved and compressions were ceased, and the resuscitation
commenced immediately at a compression ventilation ratio of effort moved to postresuscitation therapy. The aims of this therapy
30 : 2. were to continue respiratory support, maintain cerebral perfusion,
treat and prevent cardiac arrhythmias and determine and treat the
Thomas was given 1 mg of adrenaline intravenously and CPR at a cause of the arrest.
rate of 100 compressions per minute was continued for two
minutes. During this time two main focuses of resuscitation were Thomas was admitted to the ICU, intubated, mechanically venti-
implemented simultaneously, implementation of advanced life lated, sedated and paralysed. Therapeutic hypothermia was insti-
support interventions and discovery and treatment of potential tuted as per the ICU’s guideline. A cooling kit was placed on
causes of arrest. The interventions applied were making sure that Thomas and he was given intravenous ice cold saline 30 mL/kg
the ETT placement was accurate and both lungs were ventilated over 30 minutes. His core temperature was maintained at 32–34 C
°
(waveform capnography was attached); ensuring Thomas was for 24 hours. After 24 hours, Thomas was gradually warmed to a
given 100% oxygen via the ETT, confirming appropriate function- normal core temperature. Thomas remained in the ICU for 8 days
ing IV access. Potential causes of the arrest were considered, and postresuscitation care continued to ensure the best possible
hypoxia, hypovolaemia, hyper/hypokalaemia/metabolic disorders, outcome for him.

Research vignette

Kory P, Weiner J, Mathew J, Fukunaga M, Palmero V, Singh B et al. primary emphasis on speed. The main endpoints were the time
A rapid, safe, and low-cost technique for the induction of mild intervals between return of spontaneous circulation (ROSC),
therapeutic hypothermia in post-cardiac arrest patients. Resuscita- initiation of hypothermia (IH), and achievement of target tem-
tion 2011; 82(1): 15–20. perature (TT).
Abstract Results
Aim of study 65 patients underwent MTH during a 3-year period. All patients
The benefits of inducing mild therapeutic hypothermia (MTH) in reached target temperature. Median ROSC–TT was 134 min.
cardiac arrest patients are well established. Timing and speed of Median ROSC–IH was 68 min. Median IH–TT was 60 min. IH–TT
induction have been related to improved outcomes in several cooling rate was 2.6 °C/h. Complications were similar to that of
animal trials and one human study. We report the results of an other large trials. 31% of this mixed population of IHCA and OHCA
easily implemented, rapid, safe, and low-cost protocol for the patients recovered to a Pittsburgh cerebral performance score
induction of MTH. (CPC) of 1 or 2.
Methods Conclusion
All in-hospital cardiac arrest (IHCA) and out-of-hospital cardiac A protocol using a combination of core and surface cooling modal-
arrest (OHCA) patients admitted to an intensive care unit meeting ities was rapid, safe, and low cost in achieving MTH. The cooling
inclusion criteria were cooled using a combination modality of rate of 2 °C/hour was superior to most published protocols. This
rapid, cold saline infusion (CSI), evaporative surface cooling, and method uses readily available equipment and reduces the need for
ice water gastric lavage. Cooling tasks were performed with a costly commercial devices.