6 Critical Care Emergencies
CARDIOPULMONARY RESUSCITATION(ii) Non-shockable rhythms such as asystole (see p. 8) and pulseless
electrical activity (PEA) (see p. 8).
8 Establish an initial i.v. line in the antecubital fossa.
(i) Give at least 20 mL of normal saline to flush any drugs
administered, that are given after the third DC shock.
(ii) Elevate the limb for 10–20 s to facilitate drug delivery to the
central circulation.
(iii) Establish a second i.v. line unless the cardiac resuscitation is
rapidly successful
(a) ideally this line should be inserted into a central vein, either
the external or internal jugular or the subclavian
(b) a central line should only be inserted by a skilled doctor, as
inadvertent arterial puncture, haemothorax or pneumothorax
may invalidate further resuscitation attempts
(c) also, the central venous route poses additional serious
hazards should thrombolytic therapy be indicated
(d) all drugs are then given via this central line.
9 Endotracheal intubation
A skilled doctor with airway training may insert a cuffed endotracheal tube
(see p. 466). This maintains airway patency, prevents regurgitation with
inhalation of vomit or blood from the mouth or stomach, and allows lung
ventilation without interrupting chest compressions.
(i) Confirm correct endotracheal tube placement by seeing the tube
pass between the vocal cords, and by observing bilateral chest
expansion, and auscultating the lung fields and over the epigastrium.
(ii) Immediately connect an exhaled carbon dioxide detection device
such as a waveform capnograph, and look for a tracing, as the
signs above are not completely reliable
(a) never delay CPR to intubate the airway except for a brief
pause in chest compressions of not more than 10 s, as the
tube is passed between the vocal cords.
(iii) Once the airway has been secured, continue cardiac compressions
uninterrupted at a rate of at least 100/min, and ventilate the lungs
at 10 breaths/min (without any need now to pause for the chest
compressions)
(a) take care not to hyperventilate the patient at too fast a rate.
10 Subsequent management depends on the cardiac rhythm and the patient’s
condition. Keep the ECG monitor attached to the patient at all times.Definitive care
DIAGNOSIS
The ECG trace will show shockable rhythms such as VF or pulseless VT, or
non-shockable rhythms such as asystole or PEA (see Fig. 1.1).