12 Critical Care Emergencies
CARDIOPULMONARY RESUSCITATION(b) do not rely on any particular early ECG abnormality, or
expect to see ST elevation.
(v) Give 1 in 10 000 adrenaline (epinephrine) 50 μg (0.5 mL) i.v. if
there is persistent hypotension, and other treatable causes such as
hypoxia, hypovolaemia, tension pneumothorax, hyperkalaemia
or hypokalaemia have been excluded.
(a) repeat the adrenaline (epinephrine) to maintain a blood
pressure similar to the patient’s usual blood pressure, or a
systolic blood pressure greater than 100 mmHg, aiming for
an adequate urine output of 1 mL/kg/h
(b) give the adrenaline (epinephrine) and other vasoactive drugs
as soon as possible via a dedicated central venous line, which
should be inserted under ultrasound control if not already
sited.
(vi) Control seizures with midazolam 0.05–0.1 mg/kg up to 10 mg
i.v., diazepam 0.1–0.2 mg/kg up to 20 mg i.v. or lorazepam
0.07 mg/kg up to 4 mg i.v.
(a) follow this with phenytoin 15–18 mg/kg i.v. no faster than
50 mg/min by slow bolus, or preferably as an infusion in
250 mL normal saline (never in dextrose) over 30 min under
ECG monitoring.
(vii) Maintain blood glucose at ≤10 mmol/L, but avoid
hypoglycaemia.
(viii) Commence therapeutic hypothermia measures to a temperature
range of 32–34°C, according to local policy:
(a) initiate cooling following out-of-hospital VF arrest, as well as
in post asystole/PEA patients
(b) infuse 30 mL/kg cold 4°C normal saline or Hartmann’s
(c) place ice packs to the groin and axillae
(d) use a cooling blanket if available.
(ix) Transfer the patient to the ICU, catheter laboratory or coronary
care unit (CCU). Perform the following investigations but do not
delay the transfer:
(a) serum sodium, potassium, glucose and ABG, if not already
done
(b) 12-lead ECG
(c) CXR to look for correct positioning of the endotracheal tube,
nasogastric tube and central line – exclude a pneumothorax,
pulmonary collapse and pulmonary oedema.
(x) Transfer the patient with a trained nurse and doctor in
attendance. A minimum of a portable cardiac monitor,
defibrillator, oxygen and suction should be available on the
trolley.