10 Critical Care Emergencies
CARDIOPULMONARY RESUSCITATION(b) give 10% calcium chloride 10 mL i.v. for hyperkalaemia,
hypocalcaemia or calcium-channel blocking drug overdose
(c) give a bolus of potassium 5 mmol i.v. for hypokalaemia.
(iv) Hypothermia
(a) check the core temperature with a low-reading thermometer
particularly in any drowning or exposure incident (see p. 207)
(b) moderate (30–32°C) or severe (under 30°C) hypothermia
will require heroic measures such as active core re-warming
with warmed pleural, peritoneal or gastric lavage, or even
extracorporeal re-warming, when a patient is in cardiac arrest
(see p. 205)
(c) get a senior ED doctor’s help. Do not cease CPR until the
temperature is at least 33°C, or the team leader determines
futility.
(v) Tension pneumothorax
(a) tension usually follows a traumatic rather than a spontaneous
pneumothorax, particularly if positive-pressure ventilation is
used
(b) it results in extreme respiratory distress and circulatory
collapse. It may follow attempts at central venous cannulation
(c) the patient becomes increasingly breathless and cyanosed,
and develops a tachycardia with hypotension- there is decreased chest expansion on the affected side, a
hyper-resonant percussion note, and absent or diminished
breath sounds - the trachea is displaced towards the other side, and the neck
veins are usually distended
(d) this is a life-threatening situation requiring immediate relief,
without waiting for a chest radiograph (CXR)
(e) insert a wide-bore needle or cannula through the second
intercostal space in the mid-clavicular line. This will be
followed by a rush of air outwards (see p. 471)
(f) insert an intercostal drain (see p. 473).
(vi) Tamponade
(a) cardiac tamponade may follow trauma, usually penetrating,
myocardial infarction, dissecting aneurysm or pericarditis
(b) there is hypotension, tachycardia, pulsus paradoxus and
engorged neck veins that rise on inspiration (Kussmaul’s
sign). The heart sounds are quiet, the apex beat is impalpable
and PEA may ensue
(c) perform pericardiocentesis if the patient is in extremis. Insert
a cardiac needle between the angle of the xiphisternum and
the left costal margin at 45° to the horizontal, aiming for the
left shoulder (see p. 475)