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You are in the operating room, in the emergency room, or maybe on the floor. Somebody says “I can’t get a blood pressure.”

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You look at the cardiac monitor and there is still electrical activity apparent.

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1. List the 6 H’s and 6 T’s.

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2. Assume that you cannot rule out tension pneumothorax as the cause. Where and how should you decompress it?

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Pulseless Electrical Activity

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Answers
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  1. Pulseless electrical activity (PEA) has multiple causes, which you should memorize. During an emergency is not the time to be consulting a reference card (see Table 27-1).

    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. You should automatically do the following:

    • Begin bag mask ventilation and start the process of intubating the patient. If the patient is already intubated (eg, in the OR), check the tube.
    • Check the monitor. While pulseless, PEA still implies a cardiac rhythm. If the rhythm strip displays ventricular fibrillation (VF), proceed directly to asynchronous cardioversion (see the Ventricular Tachydysrhythmia Chapter 24).
    • Place 2 large-bore IVs and give some crystalloid.

    From this point on, management diverges based on your index of suspicion for each of the possible causes. 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.

    Let’s continue the case for some of the more complex yet common scenarios.

  2. In this scenario, let’s assume that your patient is a 70-year-old veteran with a 100-pack/year smoking history. He is undergoing a laparoscopic right colectomy for cancer. At the beginning of the case the anesthesiologist despairs of a peak inspiratory pressure of 45 mm Hg. The cancer is partially obstructing, so you decide to proceed anyway. Midway through the case, the patient loses his pressure. The monitor reveals a heart rate of 130. The tube looks OK. (With an open abdomen, you would feel the aorta in order to confirm hypotension.) You should give 500 mL of LR. Try to listen for breath sounds. Then insert a #18 needle directly up through the diaphragm (if the abdomen is open) or high in the midaxillary (not midclavicular) line. You don’t need to connect the needle to anything. Your patient is already on positive pressure ventilation so you cannot produce a pneumothorax. This patient has bought himself a chest tube on the side that produces a gratifying “whoosh” of air.

  3. Let’s pretend you are stat paged to the cath lab where your cardiology colleagues have placed some stiff catheters into the right ventricle of a middle-aged man. The patient is under the sheets, ...

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