Cardiac arrest meeting -use Utstein template- Database: 2012-03 KCGMH 報告日期：2012-05-16 Presenter：V.S.蕭美君

Patient group and database 3月份基隆院區共有16位OHCA 病患, 6 位IHCA病患 OHCA 14人為內科 2人為外科 IHCA 6位 5人為內科 1人為外科 以至本院無V/S為OHCA, 外院轉入已ROSC者不列入討論, 除非是EMS送來已ROSC者仍列入OHCA討論 過檢傷無V/S為IHCA

OHCA死因分析 外科:2 船難2人 內科:16 Cardiac:4 Respiratory:2 燒炭自殺:2 其他:6

OHCA

性別與年齡

發生地點-內科 公眾場所: 聖保祿PEA, 運動完, 洗病死豬槽*2, 工作場所*2

發生地點:外科

救護紀錄保存率

送醫方式 其他為醫院間轉送

EMT 反應時間 以後討論者, 發生時間太長者, 請上google map看其合理性 竹圍: dyspnea-> EMT到現場已明顯死亡

EMT使用AED之結果 有使用AED N=11 無使用AED N=2 AED不建議電擊 N=10 AED建議電擊 N=1 查無記錄表: 電子病歷*3, 遺失*2

EMT給氧方式 By EMS N=13 Mask, N=2 BVM, N=11 LMA, N=0 ETT, N=0 無記錄 N=0 兩名就醫途中變OHCA故無使用BVM

Initial rhythm in resuscitation room OHCA N= 16 兒科 = 0 內科=14 VT/VF N=0 PEA Asystole N=11 No record N = 5 外科 = 2

resuscitation –asystole CPR failure Expire at ER=10 ROSC=1 On endo，CPR Bosmin 1PC q3~5 mins

OHCA ROSC Summary ROSC =2 (皆為內科) 2 patient Admission ICU 1 case transfer to 外院RCC 1 case MBD (bedridden) ICU MBD: 清洗病死豬槽

OHCA 3月份基隆院區內科共有16例OHCA EMT有紀錄單者到院前是否急救：100% 但其中外科病患送達使用保溫袋完全覆蓋此狀況是否能執行CPR令人存疑 另本月有兩例由衛生所轉診一位插管一位未插管,未插管者到院時OHCA,家屬決議不急救,已插管者到院後簽屬DNR,兩位都死亡

IHCA 17

IHCA 基隆院區有6人為IHCA病例 IHCA急救後 ROSC 1人 存活出院: 1 人 男:女 = 2:4 入急診時檢傷級數：5人為一級 一人為三級 Cardiac arrest發生地點： 傷區 Cardiac arrest有 monitor EKG monitor rhythm? IHCA急救後 ROSC 1人 存活出院: 1 人

病患來診為為OHCA至外院求診,疑似吸入性肺炎,外帶氣管內管由外院轉入 1/37.9, 174, 161/93, E4V5M6 楊X罕 陳郭X治 吳X金 林X堅 陳X輝 陳X蔥 檢傷級數/vital signs 1/36.2, 113, 166/108, E1V1M1 病患來診為為OHCA至外院求診,疑似吸入性肺炎,外帶氣管內管由外院轉入 1/37.9, 174, 161/93, E4V5M6 病患因胸痛曾至金山醫院就醫，因今仍持續胸痛、冒冷汗、呼吸喘，故轉入。 1/35.7, 61, 107/44, E2V1M1 病患來診為意識程度改變由洗腎室入急診 1/35.2, 105, 65/33, E4V5M6 病患自行表示服用殺白蟻的藥物，量不詳，現感腹痛，血壓低 1/33.7, 134, 65/42, E1V1M1 病患來診為家屬表示病患不知道發生什麼事，發現病患時躺在外面，送到瑞礦時已無自發性呼吸、脈搏，經瑞礦急救後，現有心跳，瑞礦放置氣管內管 3/36.2, 98, 108/59, E4V5M6 病患來診為跌倒，左腳腫脹變形疑骨折，119送入 Age/gender 80/F 64/F 58/M 60/M 89/F 檢傷至CPR時間 6 hours 28hours 1min 2hours 31 hours 17hours ROSC -- + - Critical AAD CPR時之心律 PEA asystole 外院VF? Cause of CPCR 感冒嘔吐choking AMI or myocarditis AMI, pulmonary edema then ischemic bowel, septic shock Sepsis, GNB Intoxication, OPH? depression AMI with VF Intertrochanter fracture with hypovolemic shock

Case 1 Chart No.:40371XX Age:58, Gender:M 2012/03/15 16:43 Vital signs: T35.2, HR:105, R:16, SBP65/33, E4V5M6 主訴:病患自行表示服用殺白蟻的藥物，量不詳，現感腹痛，血壓低。

Present illness Ingested 殺白蟻的藥 unknown time Son and wife sent ER to hospital from home about 1 hour 病患表示不記得幾點吃的 Diaphoresis, vomiting several time and diarrhea noted but no bronchorrhea 病患表示只有喝殺白蟻藥(white powder, no smell不明量的沙白蟻藥加水大約一碗公)沒有喝酒or ingested other psychi medication at home Past hx:depression

Physical examination General appearance : alert Conscious : irritable Pupil size : 3+/3+ HEENT not anemic not icteric Chest BS : clear Heart RHB , no murmur Abdomen soft and flat no rebound pain bowel sound : NORMOACTIVE Mcburney point : negative Murphy sign : negative Extremities free movable, no edema

What can we do? 在等待毒物諮詢的結果回覆前 我們可以從病史及理學檢查中臆測病人可能是何種毒物中毒? Resuscitation as what we do in every common or uncommon day!

Rapid overview of organophosphate and carbamate Clinical syndromes Acute toxicity: evidence of cholinergic excess SLUDGE=salivation, lacrimation, urination, defecation, gastric emptying BBB=bradycardia, bronchorrhea, bronchospasm Respiratory insufficiency can result from muscle weakness, decreased central drive, increased secretions, and bronchospasm

2hours later Atropine 0.5 mg iv stat and q3mins total 5 times, 2.5 mg同時間病患口腔一直冒泡泡 then病患意識E4V1M1意識改變臉部發紺 apnea, then pulseless, start CPCR CPCR failed

Lab ABG: PH 7.437 PCO2:16.2 PO2:108.7 HCO3:10.7 TCO2:11.2 ABE:-10.1 SBE:-13.5 Sat:98.4 Cholinesterase:7101 (4499-13320) B/C:Staph. Saprophyticus

Discussion 1. duration? Metabolic acidosismeans long time Death is predictable! 2. airway protection and early oxygen supply UpToDate suggestion: deliver 100 percent oxygen via facemask; early intubation often required; avoid succinylcholine 3. antidote use (review) Atropine 2-5 mg IV/IO/IM bolus (0.05mg/kg iv in children) Pralidoxime 2g (25mg/kg in children ) iv over 30 minutes If no iv access, give 600mg im (15mg/kg in children <40kg) BZD therapy Diazepam 10mg IV if seizure, avoid dilantin

Case 2(trauma IHCA) A 89y/o female patient with left intertrochanter fracture, soon progressive to shock, No IV line at first no aggressive fluid resuscitation while patient in shock status(BP drop and ICP urine only 10c.c)

The femur is very vascular and fractures can result in significant blood loss into the thigh. Up to 40% of isolated fractures may require transfusion, as such injuries can result in loss of up to 3 units of blood.[3] This factor is significant, especially in elderly patients who have less cardiac reserve.

A fractured femur can result in 1500 to 3000 mL of hemorrhage A fractured femur can result in 1500 to 3000 mL of hemorrhage.If an artery or vein has been ruptured on the fracture, depends on the extension and seriousness of it. Normally bone fractures do not involves haemorrage, but on the event of a blood vessel rupturing, the seriousness and amount of blood loss is associated to the diameter of the vessel, (artery or vein.)

As opposed to femoral neck fractures, intertrochanteric fractures are extracapsular and significant ecchymosis may be present, depending upon the time elapsed since the injury. A large amount of blood can be lost into the thigh and hemodynamic status should be closely monitored

higher risk for hemorrhage In patients at higher risk for hemorrhage, it is prudent to obtain blood for type and screen or type and crossmatch at the time of presentation. According to retrospective studies, patients at higher risk have at least two of the following features [29,30] Age over 75 years Initial hemoglobin below 12 g/dL (SI 120 g/L) Peritrochanteric fracture

Fat embolism Clinical fat embolism syndrome presents with tachycardia, tachypnea, elevated temperature, hypoxemia, hypocapnia, thrombocytopenia, and occasionally mild neurological symptoms. A petechial rash that appears on the upper anterior portion of the body, including the chest, neck, upper arm, axilla, shoulder, oral mucous membranes and conjunctivae is considered to be a pathognomonic sign of FES, however, it appears late and often disappears within hours. It results from occlusion of dermal capillaries by fat, and increased capillary fragility.

Laboratory TestsLaboratory tests are mostly nonspecific: Serum lipase level increases in bone trauma - often misleading. Cytologic examination of urine, blood and sputum with Sudan or oil red O staining may detect fat globules that are either free or in macrophages. This test is not sensitive, however, and does not rule out fat embolism. Blood lipid level is not helpful for diagnosis because circulating fat levels do not correlate with the severity of the syndrome. Decreased hematocrit occurs within 24-48 hours and is attributed to intra-alveolar hemorrhage. Alteration in coagulation and thrombocytopenia. In summary, the diagnosis of FES may be difficult because, except for the petechiae, there are are no pathognomonic signs.

Discussion Elderly patient need more close monitor for fluid status.

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