Your patient is already on positive pressure ventilation so you cannot produce a pneumothorax. You don’t need to connect the needle to anything. Then insert a #18 needle directly up through the diaphragm (if the abdomen is open) or high in the midaxillary ( not midclavicular) line. (With an open abdomen, you would feel the aorta in order to confirm hypotension.) You should give 500 mL of LR. Midway through the case, the patient loses his pressure. The cancer is partially obstructing, so you decide to proceed anyway. At the beginning of the case the anesthesiologist despairs of a peak inspiratory pressure of 45 mm Hg. He is undergoing a laparoscopic right colectomy for cancer. Let’s continue the case for some of the more complex yet common scenarios.Ģ. In this scenario, let’s assume that your patient is a 70-year-old veteran with a 100-pack/year smoking history. In general, however, if you cannot rule out a given possibility, then you should empirically treat before you’ve made the diagnosis-if you wait to be sure, you’ve waited too long. Place 2 large-bore IVs and give some crystalloid.įrom this point on, management diverges based on your index of suspicion for each of the possible causes.If the rhythm strip displays ventricular fibrillation (VF), proceed directly to asynchronous cardioversion (see the Ventricular Tachydysrhythmia Chapter 29). While pulseless, PEA still implies a cardiac rhythm. If the patient is already intubated (eg, in the OR), check the tube. Begin bag mask ventilation and start the process of intubating the patient.You should automatically do the following: Regardless of cause, it doesn’t make any difference whether the patient arrives in the emergency department (ED) with no blood pressure or whether your patient abruptly loses a blood pressure in the operating room-you start with the same “ABC” emergency protocol. Table 32-1. The Causes of PEA, Organized as the 6 H’s and 6 T’s During an emergency is not the time to be consulting a reference card (see Table 32-1). When would you decide to stop treatment of the patient?ġ. Pulseless electrical activity (PEA) has multiple causes, which you should memorize. Assume that you cannot rule out hypovolemia as the cause. What are the landmarks you use to do a pericardiocentesis?Ĥ. Assume that you cannot rule out cardiac tamponade as the cause. Where and how should you decompress it?ģ. Assume that you cannot rule out tension pneumothorax as the cause. You look at the cardiac monitor and there is still electrical activity apparent.Ģ. Somebody says “I can’t get a blood pressure.” You are in the operating room, in the emergency room, or maybe on the floor. A Patient With Pulseless Electrical Activity Resident Readiness General Surgery 1st Ed.
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