Asthma characterized by: chronic airway inflammation reversible expiratory airflow obstruction in response to various stimuli bronchial hyperreactivity. It is estimated that asthma affects 4% to 5% of the U.S. population. Data from the National Center for Health Statistics indicate that 30.8 million people had a diagnosis of asthma in 2002. Adults missed 11.8 million workdays due to asthma. Bronchial asthma can occur at any age but typically appears early in life. Approximately one half of cases develop before age 10 and another third occur before age 40. In childhood, there is 2:1 male/female preponderance, but the sex ratio equalizes by age 30.

Cardiac Arrest in Pregnancy

Cardiac arrest in pregnancy is rare and carries a poor prognosis .

Almost 10% of overall maternal deaths reported in the United Kingdom result from cardiac arrest.

Successful resuscitation of the mother requires prompt and effective CPR with some alterations in BLS and ACLS principles.

After 20 weeks gestation, the gravid uterus may compress the inferior vena cava and impede venous return when in the supine position.

The effects of aortocaval compression must be minimized by left lateral uterine tilt using manual uterine displacement or insertion of a wedge under the right hip.

Modification of Basic Life Support

Continuous cricoid pressure during positive-pressure ventilation for any unconscious pregnant patient.

chest compressions should be performed higher than usual, slightly above the midpoint of the sternum.

Defibrillation should be performed as directed by standard ACLS guidelines.

Fetal and maternal monitors should be removed before delivering any electric shocks.

Modification of Advanced Cardiovascular Life Support

The airway should be secured as early as possible. smaller endotracheal tube may be required (0.5-1.0 mm smaller).

Pregnant patients can develop hypoxemia at a quicker rate than nonpregnant women: reduced FRC increased oxygen requirements The tidal volume to be reduced because of elevation of the diaphragm.

Differential Diagnosis

Include: amniotic fluid embolism, massive blood loss, complications of preeclampsia, acute coronary syndromes, aortic dissection, life-threatening pulmonary embolism, iatrogenic drug overdose (e.g., magnesium sulfate), or local anesthetic toxicity.

Calcium gluconate, 1 g intravenously, is the drug of choice for magnesium toxicity.

Cardiac arrest due to local anesthetic toxicity includes standard ACLS measures, and one should consider the use of 20% lipid emulsion therapy.

Perimortem Cesarean Section

The best chance of fetal survival at 24 weeks gestation and beyond is when delivery occurs no more than 5 minutes after the onset of maternal cardiac arrest. There is little chance of maternal resuscitation until the uterus is emptied. Emptying of the uterus will also improve thoracic compliance and thus ability to improve maternal ventilation.

Drowning

each year,drowning is responsible for an estimated 500,000 deaths around the world.

Among those aged 5 to 14 years,drowning is the leading cause of death worldwide for males and the fifth leading cause for females.

Drowning is a process that begins when the airway goes below a liquid surface and, if uninterrupted, may lead to death.

PATHOPHYSIOLOGY

there are no important differences in humans between drowning infresh water and drowning in salt water. Surfactant destruction, alveolitis, and noncardiogenic pulmonary edema, resulting in an increased intrapulmonary shunt and hypoxia.

Hypoxia produces: tachycardia, bradycardia, pulseless electrical activity, asystole CO, BP, PAP, PVRIt should be noted that the heart and brain are the two organs at greatest risk for permanent, detrimental changes from relatively brief periods of hypoxia.

IN-WATER BASIC LIFE SUPPORT AND RESCUE

the decision when to do basic water life support is based on the victims level of consciousness.

If the victim is conscious, rescue to land without any further medical care is the protocol.

For an unconscious victim, rescuers should check ventilation and, if possible and if indicated, attempt to provide mouth-to-mouth ventilation while still in the water.In-water resuscitation (ventilation only) provides the victim a 3.15 times better chance of surviving without sequelae.

Routine cervical spine immobilization in water rescues is not recommended.ON LAND BASIC DROWNING LIFE SUPPORT

- how the victim is removed from the water- how the victim is placed on the land

the abdominal thrust (Heimlich) maneuver is ineffective and carries significant

If vomiting occurs, turn the victim mouth to the side and remove the vomitus with a finger sweep, a cloth, or suction. ADVANCED DROWNING LIFE SUPPORT ON SITE

*Dead Body: (submersion time >1h ) do not start resuscitation

*Grade 6 : (Cardiopulmonary Arest ) - The first priority is adequate oxygenation and ventilation. - Continue cardiac compressions - Suctioning the airways - The Sellick maneuver should be used - Venous access to give drugs - Dose of epinephrine 0.01 mg/kg after 3 min. And 0.1 mg/kg each 3-5 min.*Grade 5 (Respiratory Arrest) : continue ventilation using 15 liters of o at 12 to 20 breaths/min. Until restoration of normal breathing.

*Grade 4 (Acute Pulmonary Edema With Hypotension): - O 15 l/min. by face mask until OTT be inserted (100% of cases) - Rapid crystalloid infusion (colloid solutions only for refractory hypovolemia) - Inotropic or vasopressor drugs rarely needed

Mechanical Ventilation With: - TV at least 5 ml/kg - FiO start at 1.0 then reduced to 0.45 or less - PEEP start at 5 cm HO and then increased 2 to 3 cm HO until shunt of 20% or less or PaO / FiO of 250 or more

sedative, analgesics, and MR needed to tolerate intubation

*Grade 3 (Acute Pulmonary Edema Without Hypotension): - O 15 l/min. by face mask or OTT (only 27.6% of cases have SaO > 90% and tolerate noninvasive ventilation)

- Recovery Position - Restore pH to normal

*Grade 2 (Abnormal Auscultation With Rales in Some Pulmonary Fields): - oxygen by nasal cannula

*Grade 1 (Coughing With Normal Lung Auscultation): - do not need any O or respiratory assistance

*Rescue (No Coughing, Foamy Secretions, or Difficulty Breathing): - released from the accident siteOther InterventionsNasogastric tube.orogastric tube. Bronchoscopy.Surfactant therapy.Echocardiography.Other Treatment Considerations

Initiation of appropriate management of hypoglycemia and other electrolyte imbalances, seizures, bronchospasm and cold-induced bronchorrhea, dysrhythmias, and hypotension may be necessary in the drowning patient.

Treatment of metabolic acidosis (PH