Chapter 1: Emergency

Medicine
Cardiopulmonary Resuscitation
Advanced Life Support
Office Emergencies
Medical Emergencies (Cardiac Dysrhythmias)
Summary of CPR
Other Medical Emergencies
Shock
Blood and Blood Components for Emergency Use
 EMERGENCY MEDICINE
Cardiopulmonary Resuscitation
1. Rescue breathing: Adult victim
a. Check responsiveness: shake or tap gently and ask "ARE YOU OK ?"
b. If unresponsive yell for help
c. Open the airway: head tilt/chin-lift to open airway, and check for
obstruction. Remove if present
d. Check for breathing: if no breathing then give 4 quick breaths (Observe
chest rise)
e. Check for pulse (Carotid) for 5-10 seconds: if .pulse is present but there is
no breathing then
f. Start rescue breathing: inflate @1 breath every 5 seconds. Continue for 1
minute
g. Reassessment: check pulse and breathing, if breathing then stop CPR. If
no breathing but pulse present, then just continue ventilations. If no
breathing and no pulse, then begin CPR
h. Start chest compressions over sternum: using heel of hand with
fingertips off sternum and with elbows straight; compress 181 /2 to 2
inches @ 80 to 100/ minute
i. Provide proper ventilations: give 2 breaths after 15 compressions if
working alone or 1 breath to every 5 compressions when two rescuers
are present

Note* Do not perform a precordial thump in an unwitnessed event

2. Rescue Breathing: Infant victim

a. Check responsiveness
b. If unresponsive call for help
c. Open airway: if obstructed then clear
d. Check for breathing: if no breathing then cover victim's mouth and
nose with rescuer's mouth and give 4 puffs of air (Observe chest rise)
e. Check for pulse (Brachial): if pulse present but no breathing
f. Start rescue breathing: inflate @ 1 breath every 3 seconds, continue for 1
minute
g. Reassessment: check pulse and breathing if victim is breathing then stop
CPR- if victim is not breathing and pulse present then continue
ventilations- if victim is not breathing and has no pulse then start chest
compressions
i. Infant chest compressions should incorporate 2-3 fingers on the sternum
centered on an imaginary line between the nipples, compressing
vertically 1/2 to 1 inch at a rate of 100/minute ventilations occurring after
every 5 compressions

Note* Do not perform a precordial thump in an unwitnessed event

3. Rescue breathing: Child victim
a. All of the above holds true except that the rescuer feels for the carotid
pulse compressions occurring one finger width above the substernal notch
using the heel of the hand at a compression rate of 80-100/ minute-
maintain cycles of 5 compressions to every 1 ventilation

NOTE* Do not perform a precordial thump

Advanced Life Support

1. Advanced cardiac life support: includes the use of drugs, defibrillation,
intubation and military antishock trousers (MAST)- the basic protocol is as
follows:
a. Begin basic CPR (Airway-Breathing-Circulation)
b. Determine circumstances (Past history-current medications) c. Begin IV and
intubate
d. Determine cardiac rhythms
e. Determine blood gases
f. Begin appropriate drug therapy. These drugs include:

i. Atropine:
 decreases vagal tone to increase heart rate
 used in sinus bradycardia/high degree AV block
 dosage- .5mg IV Q 15 minutes up to 2mg.

ii. Bretylium:
 used in V-fibrillation and V-tach when lidocaine and countershock fails
 dosage v-fib: 5-10gm/kg bolus Q 15 min to max 30mg/kg
 dosage v-tach: 5-10 mg/kg IV over 10 minutes, then 1 to 2 mg/min IV drip

iii. Calcium:
 should only be used to treat acute hyperkalemia, hypocalcemia, and
calcium channel blocker toxicity (there is no data showing its
effectiveness during CPR)
 increases cardiac contractility and excitability
 used in asystole
 dosage: calcium chloride 2-4 mg/kg Q 10 minutes (Approx 500 mg)
 used in pump failure
 dosage: 2.5-1 Omicrograms/kg/min

iv. Dopamine:
 alpha, beta, and delta agonist
 used to support cardiac output, BP and renal perfusion in shock
states
 dosage: start at 2-5 micrograms/kg/min, titrate to effect 20
micrograms/kg/min
 large dose has mostly alpha effect
v. Epinephrine:
 alpha and beta agonist, increases heart rate and contractility
 used in asystole, V-fibrillation, and cardiac arrest
 dosage: .5 to 1.0mg (5-10 ml of 1-10,000) IV Q 5 min

vi. Furosemide (Lasix):

 loop diuretic and vasodilator
 used for pulmonary edema and congestive heart failure
• dosage: starting dose is 0.5, mg/kg IV and total dose not to exceed 2.0 mg/kg IV

vii. Isoproterenol (Isuprel):

 pure beta agonist
 increases heart rate, contractility and consequently cardiac output
 used in asystole, symptomatic heart block and bradycardia
 dosage: 1 mg in 500 cc D5W to give a starting dose of 2 mcg/min, titrate
to effect (to achieve a heartrate of 60 beats/minute)

viii. Lidocaine (Xylocaine):

 decreases automaticity and raises v-fib threshold
 used to suppress PVC's, v-tach and v-fib
 gm/kg 50-100gm bolus, then 2-4mg/min IV drip

ix. Procainamide (Pronestyl):

 decreases cardiac excitability, decreases automaticity of ectopic
pacemakers, and slows conduction
 used to suppress ventricular ectopics when lidocaine fails
 dosage: 100mg IV with a rate of 20mg/min until dysrhythmia disappears or
hypotension ensues, QRS complex is widened by 50%, or total of 1 gm of
drug is injected

x. Propranolol (Inderal):
 beta blocker (to be used with caution in patients with COPD, diabetes and heart
failure
 used to control recurrent ventricular and atrial tachydysrhythmia
 dosage: 1 mg IV Q 5 minutes to 5 mg total (total dose not to exceed 0.1 mg/kg)
 must administer slowly

xi. Sodium Bicarbonate:

 used to counteract metabolic acidosis
 dosage is based on blood pH or empirically, 1 mEq/kg IV (50-100 mEq or 1-2
amps)

g. Cardioversion as necessary (Defibrillation) for ventricular fibrillation Procedure as

follows:
1. Use paste or pads on skin
ii. Charge defibrillator with SYNCHRONIZATION switch off
iii. Place paddles as directed on the handles: one on the right upper
sternum and the other on the left anterior axillary line
iv. Apply paddles with firm pressure (turn off oxygen)
v. Shout," clear", make sure no one is touching the victim vi. Press both paddle
switches simultaneously to fire the unit
vii. Repeat as necessary : Start at 200-300 joules- maximum output
400 joules

Office Emergencies
1. Syncope- Vasovagal reflex (Primary shock; fainting)
a. Defined as transient loss of consciousness due to sudden release of the
arterial vasomotor tone and temporary insufficiency of cerebral circulation
b. Causes are sudden extreme fear or pain or the effect of severe injury
c. Differential diagnosis: epilepsy, hyperventilation, hysteria , carotid sinus
syndrome, cardiac arrhythmia, drugs and orthostatic hypotension d. Signs
and symptoms: pallor, sweating, slow pulse, yawning and marked transient
hypotension
e. Treatment is supportive: recumbent position, take B.P., pulse, spirits of
ammonia, O2 and drugs (Atropine/Ephedrine) only if previous treatment fails

2. Local Anesthetic Toxicity

a. Causes are too much volume or too concentrated solution; extreme
rapid absorption
b. Reactions- rapid and delayed; with cerebral stimulation and/or depression;
respiratory stimulation; cardiac depression; hypotension; shock
c. Signs and Symptoms: apprehension , nausea, BP elevation, convulsions,
perioral tingling, or most seriously, post-ictal depression, respiratory depression,
hypotension respiratory and cardiac arrest
d. Treatment- mental changes/watch patient, respiratory depression/O2,
hypotension/ vasopressors i.e. Ephedrine 20 mg IM convulsions/Valium 5
mg IV, and CPR if necessary

Note* Ephedrine raises BP and causes tachycardia while Vasoxyl raises BP

without tachycardia (due to the alpha effect)

3. Anaphylactic Reactions
a. These are toxic reactions that occur in persons who are allergic by
heredity or who have become sensitized to a given drug or therapeutic
agent after previous administration. Respiratory obstruction is the
cause of death
b. Reactions- anaphylactic shock, angioneurotic edema (swelling of soft
tissues of throat), asthma with acute bronchospasm, urticaria and pruritus
c. Signs and symptoms of anaphylactic shock - skin wheals, itching,
angioedema, laryngeal edema, bronchospasm (wheezing) dyspnea,
cyanosis, apnea, vomiting, hypotension, cardiorespiratory collapse and
death
d. Treatment of anaphylactic shock (must be immediate)- .5cc epinephrine IV
or IM (children 0.01 mg/kg), tourniquet and .25cc epinephrine at injection site,
O2 & airway, Solu-cortef 200 mg IV and CPR if necessary

4. Allergic Reactions:
a. End organ response of the skin
b. Symptoms are hives, (urticaria), bronchial asthma, and G.I. upset c.
Treatment: 25-50 mg IM Benadryl- if severe then treat as if anaphylactic
reaction- if tongue swelling use epinephrine

5. Acute asthmatic attack:

a. This is an intermittent airway obstruction, which is reversible- can be
acute and severe leading to respiratory failure
b. Causes- allergies, irritants, infections, extreme cold, drugs and emotion
c. Signs and symptoms- recurrent attacks of wheezing dyspnea and cough
d. Treatment- reassurance, rest, O2, drug therapy (epinephrine .5cc 1:1000
subQ every 20 min up to 3 doses - if no relief then aminophylline 5-6
mg/kg over 20 minutes, hydrocortisone 100mg)

6. Seizures (major convulsions):

a. Defined as convulsive disorders characterized by abrupt transient
symptoms of motor sensory, psychic, or autonomic nature, frequently
associated with change in consciousness. Changes thought to be
secondary to sudden transient alterations in brain function associated
with excessive rapid electrical discharge in the gray matter.
b. Causes: idiopathic, pathological states (brain tumor, CVA, head trauma),
local anesthetic toxicity, and intoxications
c. Signs and symptoms in grand mal (major epilepsy)- aura, severe
generalized clonic, convulsive body movements followed by a period of
flaccid coma, then a period of sleep (post-ictal depression)- with status
epilepticus: recurrent and severe seizures with short or no intervals
between seizures
d. Treatment- except in status epilepticus no specific treatment is necessary
except to protect patients from hurting themselves- in status epilepticus
start with Valium, then Dilantin, then phenobarbital prn

7. Hypertension:
a. Defined as persistent elevated BP above normal for the patient
(borderline hypertension BP>140/90)
b. Signs and symptoms- headache, convulsions, visual changes, with acute
rise in BP
c. Treatment- start supportive therapy and reduce BP with sublingual
nifedipine 10mg (Procardia) then send for medical evaluation

8. Insulin Shock (hypoglycemia):

a. Defined as low blood sugar that occurs when a diabetic who has taken
insulin, fails to ingest food or engages in too strenuous exercise
b. Treatment- if conscious and able to swallow then give orange juice- if
unconscious then give IV glucose 20 to 50 ml. of 50% solution

NOTE* If the diabetic patient is seen when unconscious, and if the diagnosis of
coma or insulin reaction is in doubt, give 50% glucose IV- this will
overcome insulin reaction but will not generally harm patient in
diabetic acidosis
Medical Emergencies (Cardiac Dysrhythmias)
1. Myocardial Infarct (uncomplicated): Characterized on EKG by big Q waves
a. Monitor EKG
b.100% O2 with nasal cannula
c. Start IV lines with D5W
d. Sublingual nitroglycerin can help
e. Relieve pain with morphine sulfate
f. Do blood gases/pH/electrolytes
g. Consider use of prophylactic lidocaine

2. Asystole: Characterized by a flat line on the EKG

a. Use basic CPR, begin IV, intubate
b. Give epinephrine and bicarbonate
c. If ineffective give calcium chloride
d. If ineffective give atropine
e. If ineffective give isoproterenol'
f. If ineffective repeat steps b-e and as a last resort can give epinephrine
intracardially or using a transvenous or external pacemaker

3. Ventricular Fibrillation: The gravest of all arrhythmias characterized by

irregular and uncoordinated movements of the ventricles
a. Use basic CPR, begin IV's, intubate (if unconscious)
b. Use precordial thump only if witnessed arrest then defibrillate with 200-
300 joules- repeat prn
c. If unwitnessed event do not use countershock: first start with epinephrine
and bicarbonate
d. If no response give epinephrine and bicarbonate
e. Defibrillate at 400 joules
f. Use lidocaine or procainamide
g. If no response use bretylium
h. After successful conversion use lidocaine drip

4. Ventricular Tachycardia:
a. Begin lidocaine
b. Use CPR if no pulse/O2/ IV's (and unconscious)
c. Use precordial thump if witnessed event
d. Consider cardioversion and procainamide or bretylium if lidocaine
ineffective

5. Third degree AV heart block:

a. Use atropine .5mg IV followed by isoproterenol prn b. Pacemaker
6. Premature ventricular contractions (PVC's): (frequent) May lead to V-ib
(if untreated)
a. Lidocaine 100mg IV bolus followed by lidocaine IV drip

Wolff-Parkinson-White syndrome:
a. Characterized by a short P-R interval and prolonged QRS time. There is a
40% incidence of episodes of paroxysmal tachycardia, atrial fibrillation and
atrial flutter, as well as the possibility of sudden death. Can occur in healthy
individuals
b. Treatment: Digitalis, quinidine, propranolol, artrial pacing

Summary of Cardiopulmonary Resuscitation

1. Establish the diagnosis: Apnea, no pulse, absence of heart sounds,
absence of responsiveness, ashen gray color
2. Summon help: Time is critical; you only have 4-6 minutes to reestablish
ventilation
3. Do not thump the patient's chest (not part of CPR any more)
4. Check for absence of breathing first. Displace the mandible forward, and
clear the airway manually, then give 2 rapid respirations
5. Place support under patient's back and start mouth-to-mouth breathing
and external cardiac compression (5:1 with two rescuer sequence or 15:2
solo). Depress the sternum 4-5 cm (1.5-2 inches)
6. Insert ET tube to ventilate with 100% oxygen (only by experienced
personnel)
7. Start IV infusion by needle or cutdown. Administer epinephrine and
sodium bicarbonate and repeat bicarbonate injections until arterial blood
gases and pH results are known
8. Monitor EKG
a. If V-fib: Closed chest compression, epinephrine, sodium bicarbonate,
defibrillate (if not effective repeat countershock)
9. Inject epinephrine, and if defibrillation not successful, repeat
10. Following restoration of heart function inject lidocaine for excessive
ventricular irritability
11. If asystole is present, heart function may resume following myocardial
oxygenation by ventilation and external cardiac compression
12. If asystole persists inject epinephrine and sodium bicarbonate., calcium
chloride and isoproterenol prn
13. If electromechanical dissociation is present take therapeutic
steps as with asystole
14. Corticosteroids may be used to decrease cerebral edema
15. Postcardiac arrest therapy includes corticosteroids, diuretics,
hypothermia, and hyperventilation. Monitor arterial blood gases, BP, EKG,
CVP (central venous pressure), urine, electrolytes, and chest x-ray

Other Medical Emergencies

1. Narcotics Overdose:
a. Give Naloxone (0.2-0.4 mg IV or IM/ in children .01 mg/kg: repeat Q 5
min)

2. Acetaminophen Overdose (APAP):

a. The major toxic effect is centrilobular necrosis of the liver with toxicity
likely to occur after a minimum acute ingestion of about 10g (or 30
acetaminophen tablets)
b. Perform plasma APAP levels- treatment based accordingly
c. Emesis with ipecac or gastric lavage
d. Administer ACETYLCYSTEINE if elevated APAP plasma level

3. Salicylate Overdose: (the most common cause of fatal drug ingestion in

the pediatric age group) (Reyes syndrome)
a. There is a relationship of signs and symptoms to the amount of ASA
ingested
i. Mild: >100mg/kg: hyperventilation, lethargy, tinnitus
ii. Moderate: 200-300mg/kg: hyperventilation, vomiting, sweating, vertigo,
hallucinations
iii. Severe: 300-400mg/kg: hyperventilation, seizures, coma, shock
b. Treatment begins with emesis with ipecac then gastric lavage
c. Alkalinize the plasma ( helps promote secretion of salicylates) with push
doses of bicarbonate
d. If shock present start IV with Ringer's lactate e. Start dialysis if renal failure

4. Poisoning:
a. Each type of poisoning is treated differently a. Begin basic CPR if necessary
b. Determine ingested substance and give antidote if available

NOTE* It is better to call hotline first for specific directions in the treatment of
specific ingested agents

c. If unconscious- protect airway with ET tube, lavage with 28 French NG

tube, use 300m1 normal saline for adults (activated charcoal can be added)
d. If conscious- use syrup of ipecac to induce vomiting, ambulate patient, and
give large quantities of water

5. Pulmonary Embolism: Complete or partial blockage of the pulmonary

vessels from an intravascular clot originating elsewhere in the body, usually
the deep veins of the lower extremity
a. Signs and symptoms can include chest pain, dyspnea, cough, sweats,
syncope, respirations >16/min, pulse >100/min, temp>37.8 degrees
C, phlebitis and edema
b. EKG can show ST-T wave changes
c. Presumptive diagnosis made by lung scan- definitive diagnosis made
by pulmonary angiogram
d. Treat with bedrest, then Heparin 5000 units as loading dose followed by
continuous infusion (25,000 units added to 500 ml D5W administered via
IVAC)
e. Prior to Heparinization do PTT- during treatment adjust to keep PTT 2X
normal
f. If thrombophlebitis present treat with elevation and moist heat (may need
antibiotics)

6. Hypertensive Emergencies:
 Hypertensive encephalopathy
 Malignant Hypertension
 Accelerated Hypertension
 Hypertensive Crisis
a. Diagnosis of Hypertensive encephalopathy or accelerated malignant
hypertension is a clinical one and demands immediate aggressive therapy
to lower BP
b. Treatment initially should be Diazoxide (Hyperstat) 300mg by rapid IV
bolus or can give hydralazine (should give Furosemide simultaneously-
prevents fluid retention)

7. Malignant Hyperthermia (also see Chapter Anesthesia, Section: Other

Medical Complications of Anesthesia):

Defined as a catastrophic reaction to general anesthesia An inherited trait

Incidence of 1 in 20,000

a. With exposure to inhaled anesthetic agent the patient exhibits

fasciculations and increased muscle tone, with jaw clenching during the
induction of anesthesia a typical early sign and body muscles becoming
rigid and excessive body heat produced
b. Anesthesia must be discontinued
c. Patient must be cooled
d. INTRAVENOUS DANTROLENE SODIUM HAS A THERAPEUTIC EFFECT
e. If suspicious of malignant hyperthermia pre-op do CPK LEVEL- THIS
LEVEL IS ELEVATED IN 79% OF THE PATIENTS WITH MALIGNANT
HYPERTHERMIA
f. Early signs:
i. Tachycardia
ii. Tachypnea
iii. Unstable BP
iv. Arrhythmias
v. Dark blood in the surgical field
vi. Cyanotic mottling of the skin
vii. Profuse sweating
viii. Fever
ix. Fasciculations
g. Suggested treatment regimen:
i. Stop anesthesia
ii. Hyperventilate with 100% oxygen (8-10 liters/minute)
iii. Start Dantrolene sodium IV as soon as possible (starting dose 1
mg/kg up to a maximum cumulative dose of 10 mg/kg by rapid infusion)
iv. Start Procainamide IV if required for arrhythmias
v. Initiate cooling
-IV iced saline (not Ringer's)
 surface cooling with ice and hypothermia blanket
 Lavage of stomach, bladder and rectum
vi. Correct acidosis and hyperkalemia with sodium bicarbonate
vii. Monitor EKG, temp, urinary output, electrolytes, arterial pressure and
blood gases, pH, and electrolytes
viii. Maintain urine output of at least 2 ml/kg/hr: administer Mannitol and
Furosemide (if necessary)
ix. If necessary administer Insulin to provide energy to the cells and
normalize the pH
x. Administer oral Dantrolene for 1-3 days after the crisis

NOTE* Avoid amide local anesthetics if a patient has a history of malignant

hyperthermia reaction
NOTE* Malignant hyperthermia is most frequently seen when halothane and
succinylcholine are used together
Shock
The mechanism of shock is poorly understood, however, this phenomenon
results in inadequate tissue perfusion with accompanying cellular injury
and metabolic disturbances. Shock cannot be defined but it can be classified
by etiologic means
1. General clinical presentation:
a. Tachycardia
b. Hypotension
c. Low tension pulse (thready pulse)
d. Collapsed superficial peripheral veins
e. Oliguria
f. Hypothermia
g. Metabolic acidosis

2. Etiology:
a. Hypovolemic: Caused by a reduction in circulating blood as a result of
traumatic injury, GI bleed, crush injuries, burns, massive diarrhea, and
peritonitis
b. Septic: Caused by infections that produce an endotoxic or exotoxic
reaction. Most common gram (-)'s are E. coli, Proteus group, Pseudomonas,
Klebsiella and meningococci. Less often involved are gram (+)'s such as
staphylococci, streptococci, and clostridia
c. Neurogenic: Severe injury to the spinal cord or brain can cause a loss in
vasomotor tone resulting in vasodilation and hypotension from the loss of
peripheral vascular resistance. Also psychogenic factors such as the sight of
blood or surgery can produce shock
d. Cardiogenic: Produced by hypotension arising from inadequate cardiac
output as a result of serious arrhythmias, tamponade, Ml, CHF, and
pulmonary embolism
e. Metabolic: Caused by alterations in the fluid electrolyte balance as a
result of systemic diseases such as diabetic acidosis, renal failure, or chronic
respiratory diseases
f. Anaphylactic: Occurs following the injection of heterologous sera,
penicillin and other medications

3. Treatment of shock:
a. Assess the physical status of the patient
b. Lie the patient down and keep him/her warm
c. Maintain airway administering oxygen at 8-10 liters/minute. If patient
unable to breath on their own use Ambu bag (use- CPR if necessary)
d. IV fluid replacement to avoid dehydration. Do not use lactate solutions

NOTE* Expanding the intravascular volume is the primary goal in the initial
treatment of hypovolemic shock

e. Vasopressor drugs can be used providing there is sufficient blood volume to be

effective (the mechanism and etiology of shock dictates the specific drug)
f. Lab studies should be instituted such as pH, pO2, pCO2, serum electrolytes,
BUN, lactic and pyruvic acids, and hematocrit
g. Measure the urine volume (normally it should be above 30 ml/hour
persistent oliguria below 25 ml/hr for more than 2 hours may cause renal cell
necrosis)
g. If infection is suspected cultures should be performed, and appropriate
antibiotics initiated
h. For allergic/anaphylactic reactions treatment as mentioned above should
be instituted
 NOTE* Patients with a history or suspicion of penicillin allergy may be tested
as follows: Dilute penicillin G to a concentration of 1,000 units per ml and
place 1 drop on a skin scratch on the forearm. If the test is positive a
wheal will be seen within 15-20 minutes. If the test is negative, inject a
small amount of this solution intradermally to double check. This
indicates the decreased probability of anaphylactic response but does not
totally rule out an allergic state. Keep a "shock kit" immediately available
because even a test can initiate anaphylactic shock. Also the risk of
testing is that patients may become iatrogenically sensitized to future doses

Blood and Blood Components for Emergency

Use (also see Ch. 11 Fluid Management)
1. Red Blood Cells
a. Description:
i. Available as "packed RBCs" of 250 cc, split units of 125 cc, or quad
packs for newborns
ii. Anticoagulants are used to prevent clotting and a small residual amount of
plasma is present
iii. Units can be prepared and combined with special filters to prevent
febrile reactions (leukocyte poor)
iv. Unit can be washed to prevent allergic reactions (washed RBC's)
v. One unit can raise the hematocrit by 3% or Hb by 1 gm.
b. Compatibility:
i. The unit must be ABO compatible, but Rh compatibility not required but
preferred
ii. Rh positive blood can be given to patients especially those over 50 years
of age, who are expected to use multiple units (10% will develop Rh
antibodies 3-4 months later, and by this time the transfused Rh+ cells
have been cleared)
iii. When Rh- units are in short supply they should be saved for women of
child bearing age
c. Alternatives:
i. Autologous transfusions: patients can donate up to 3 units of blood prior to
surgery and have these units available if subsequent bleeding occurs during
the procedure (the safest)
ii. Directed transfusions: Patients can elect to have friends and relatives donate
blood for upcoming surgery
iii. Perioperative cell salvage: Patients may elect in certain operative procedures
to have blood lost during surgery, recollected, filtered and transfused (sterile
orthopedic procedures and abdominal aortic aneurysms)
c. Indications for RBC's:
i. Hypovolemia due to acute blood loss and associated with one or more of
the following:
 Acute bleeding with an actual or anticipated blood loss of 750 ml or
more
 Systolic blood pressure <90 mm
 Tachycardia (pulse > 100)
 Hct < 30% and documentation of a fall of 5% or more within 24 hours or
10% or more within one week
 Central venous pressure < 3 cm/H20
ii. Chronic anemia:
 Uncomplicated: Hct < 24 or Hgb < 8 mg (and not due to acute blood loss)
with anemia syndrome
 Complicated: Hct < 30% or Hgb < 10% with complications affecting
oxygenation (cardiac or respiratory insufficiency)
 Anesthesia pre-op: Hct < 30% or Hgb < 10mg
iii. Hemodialysis

NOTE* RBC's must be used within 4 hours after removal from the refrigerator
and must return within 20 minutes to the Blood Bank if not used. Warming
can result in bacterial proliferation if allowed to warm to room temperature
before returning to refrigeration

d. Adverse reactions:
i. Infectious reactions:
 AIDS: Risk is 1:20,000 to 1:40,000 for each unit transfused
 Hepatitis (B C): less than 1
 MV
ii. Noninfectious reactions
 Febrile: fever reaction most common. This reaction involving circulating
antibodies in the recipient which react to HLA antigens in infused
granulocytes
 Allergic: associated with circulating serum antibodies within the
recipient to infused immunoglobulins within the small amount of residual
plasma of the red cell unit (hives, serum sickness, anaphylaxis)
 Hemolytic: is a result of circulating naturally occurring antibodies in the
recipient to antigens on the RBC's causing cell lysis
 Graft vs. host disease: engraftment and multiplication of donor blood cells
in an immunosuppressed recipient are possible, and here, immunocompetent
lymphocytes become engrafted and cannot be rejected

2. Platelets:
a. Description: Are a concentrate separated from a single donor by
plasmapheresis from whole blood containing 5.5 x 1011 platelets in 200
300 cc of plasma and anticoagulant, and can be expected to raise the adult
platelets count by 60-80,000 unless platelet antibodies are present
b. Compatibility: ABO compatibility is preferred, but in emergencies or short
supply any ABO group can be used (Rh is not a factor).
c. Alternatives: Random donor platelets are obtained from a single unit of
whole blood and contain 1 /10 the number of platelets in 30-50 cc, and 6-
10 units are standard suggested therapy
d. Indications:
L Prophylaxis:
 Platelet count < 20,000/mm3 or anticipated drop below 20,000 in the
 next 24 hours
 Platelet count < 80,000 with surgery anticipated or in the acute post-op
period
 A platelet function defect with surgery anticipated or in the acute post-op
period
i. Bleeding:
 latelet count < 20,000/mm3
 latelet function defect (known or suspected)
e. Adverse reactions: Same risks as RBC's

3. Cryoprecipitate:
a. Description: Prepared by thawing fresh frozen plasma at 4°C and
recovering the cold precipitate. Each bag of 'Cryo' contains 90 or more Factor
VIII units and at least 150 mg of fibrinogen in less than 15 ml of plasma
b. Compatibility: ABO compatibility is preferred but not required in
emergency situations
c. Alternatives: Fresh frozen plasma can be used if there are associated
deficiencies of individual coagulation factors, massive blood transfusion, or
when cryoprecipitate is in short supply
d. Indications:
i. Von Willebrand's Disease
ii. Hypofibrinogenemia associated with bleeding or surgery (perioperative)
iii. Dysfibrinogenemia associated with bleeding or surgery
iv. Uremia associated with bleeding
v. Factor XIII deficiency
e. Adverse reactions: Same as with RBC's

4. Fresh Frozen Plasma:

a. Description: Is the anticoagulated clear liquid portion of blood that is
separated and frozen within a few hours of Whole Blood Collection. A unit
of FFP contains about 200 units of Factor VIII as well as other
coagulation factors. Volume is 250 cc.
b. Compatibility: ABO compatibility required
c. Alternatives:
i. Specific coagulation factors (cryoprecipitate for low fibrinogen or von
Willebrand's disease)
ii. Crystalloid or albumin is the preferred product for volume expansion d.
Indications:
1. Replacement of isolated deficiencies (Factor II, V, VII, IX, XI) ii. Reversal of
Warfarin effect
iii. Massive blood transfusion (greater than 1 blood volume within several
hours)
iv. Antithrombin III Deficiency
v. Thrombotic thrombocytopenia purpura
e. Adverse reactions: Same as with RBC's
 NOTE* Allergic reaction, dermal and anaphylaxis can be severe.
Treatment includes Benadryl 50 mg 1M STAT repeated Q 10-20 5.
minutes prn. Steroids and fluids may be necessary in severe
reactions
Albumin
a. Description: A solution containing the albumin component of human
blood, which can effect immediate and prolonged restoration of circulating
blood volume by causing a shift of fluid from the interstitial spaces into the
circulation and slightly increasing the concentration. of plasma proteins
b. Action: 25% albumin will draw approximately 3.5 times its volume of
additional fluid into the circulation within 15 minutes, and provides a means
of replacing human plasma proteins
c. Indications:
i. Plasma or blood volume deficit secondary to surgery, hemorrhage, burns, or
trauma: to support BP by expanding the plasma volume
ii. Hemolytic disease in the newborn
iii. Hypovolemic shock: to restore blood volume in increase CO
iv. Hemodialysis: for the treatment of shock or hypotension when the
patient is fluid overloaded
v. Acute or chronic liver disease
d. Contraindications: History of hypersensitivity or severe anemia or CHF
e. Precautions: Solutions containing 5% albumin are usually indicated for
hypovolemic patients, 25% solutions should be used when fluid and Na+
intake must be minimized (cerebral edema and pediatric patients)
f. Adverse reactions: Rare