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Mega Code

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ACLS new changes and what to remeber for any Mega Code or Code Blue

ACLS new changes and what to remeber for any Mega Code or Code Blue

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  • 1. Sense
  • 2. React
  • 3. Result !!
  • 4. TODAY Review the latest changes in BLS & ACLS Review of most common & important EKG Rhythms. ACLS pulseless algorithm
  • 5. Responsiveness
  • 6. Primary A,B,C,D
  • 7. Primary A,B,C,D 2005 International Consensus Conference.Circulation 2005;112:III-17
  • 8. Secondary A,B,C,D
  • 9. Secondary A,B,C,D 1 1 2 2 3 3
  • 10. Secondary A,B,C,D
  • 11. Secondary A,B,C,D 1. Primary confirmation 1. Visualizes ETT goes through the vocal cords 2. Observes vapors in the tube 3. Chest rise 4. 5 point auscultation of the chest
  • 12. Secondary A,B,C,D
  • 13. Secondary A,B,C,D
  • 14. Secondary A,B,C,D – Circulation 1. Establish IV access 2. Identify rhythm  monitor 3. Administer drugs 4. “appropriate for rhythm and condition”
  • 15. Simultaneous recording of aortic diastolic (red) and right atrial (yellow) pressures during CPR in which 2 ventilations are delivered within 4-second time period Ewy, G. A. Circulation 2005;111:2134-2142
  • 16. Secondary A,B,C,D
  • 17. Secondary A,B,C,D – Deferential Diagnosis – search for and treat identified reversible causes
  • 18. Secondary A,B,C,D 6 H’s 6 T’s – Hypovolemia – Tablets – Hypoxia – Thrombosis “coronary” – Hydrogen Ions “acidemia” – Thrombosis “Pulmonary” – Hyperkalemia / – Tension pneumothorax Hypokalemia – Tamponade, Cardiac – Hypothermia – Trauma – Hypoglycemia
  • 19. – Checking the heart rhythm – Checking the pulse – inserting airway devices – administration of drugs should be done
  • 20. Asystole – “Flat line” protocol: 1. Check leads attachment. 2. Check leads selection 3. Power on/off 4. Check the gain
  • 21. VF pulseless VT
  • 22. EKG review 1. Tachy vs. Brady 100 < rate < 60 Three questions: 1. Rate 1. Supraventricular vs. 2. QRS narrow or wide ventricular 3. P wave & PR interval 2. Source of rhythm & blocks
  • 23. Medications 1. Why? (Actions) 2. When? (Indications) 3. How? (Dose) 4. Watch Out! (Precautions)
  • 24. What is the most important medication in the cardiac arrest?
  • 25. O2
  • 26. How to give the medication during CRP? • I.V. • E.T.T – Fast I.V. Bolus. – 2-3 times the I.V. dose – 10 cc N.S. flush. – Raise the arm. – Diluted 10cc N.S. – Use central venous – 3-4 ambo-bag “to access if it available. diffuse the medication”
  • 27. Which Meds can be given through E.T.T?
  • 28. Which Meds can be given through E.T.T? NAVEL Naloxon Atropine Vasopressin Epinephrine Lidocaine
  • 29. Epinephrine • Action : α & β – adrenergic agonist activity • Indication: all Pulseless rhythms. • Dose: • initial dose 1mg ( 10mL of 1:10 000 solution ) • Additional doses of 1mg every 3- 5 min • No maximum dose. • Precautions: • PVC with digitalis. • Hypertension • Myocardial ischemia
  • 30. Vasopressin • Survival higher in patients who had higher endogenous vasopressin 1,2 • Action : • Vasoconstriction by direct stimulation of the smooth muscle V1 receptor. • Combination with epinephrine resulted in decreased cerebral perfusion 3 • increase coronary perfusion and cerebral oxygen delivery during CPR 4 • Has no β – adrenergic activity. • Indication: all Pulseless rhythms. • Dose: – Start with 40 units I.V. once. – Don’t combine with epinephrine
  • 31. Vasopressin & Epinephrine no statistically significant differences between vasopressin and epinephrine for death within 24 hrs or death before hospital discharge after a successful CPR. • There is thus insufficient evidence to support or refute the use of vasopressin as an alternative to or in combination with epinephrine in any cardiac arrest rhythm.
  • 32. Atropine – Action : vagolytic action “SA and AV node” – Indication: asystole & PEA with rhythm < 60/min . – Dose: – initial dose 1 mg – Additional doses every 3-5 min – max dose 3 mg/Kg – Precautions: – Myocardial ischemia
  • 33. Amiodarone – Action : Na+, K+, Ca++ channel blocker and α & β Blocker. – Indication: shock refractory VF/ Pulseless VT. – Dose: – initial dose 300 mg bolus – Additional doses of 150 mg/kg – Infusion dose of – 1 mg/min for 6 Hr ( 360 mg ) then – 0.5 mg/min for 18 Hr ( 540 mg ) – Maximum dose of 2.2 Gram / 24 Hr – Precautions: – Prolonged QT. – Hypotension – Negative Inotrope
  • 34. Lidocaine – Action : suppress ventricular arrhythmia, ectopy and prolong the refractory period. – Indication: shock refractory VF/ Pulseless VT. – Dose: – initial dose 1-1.5 mg/Kg – Additional doses of 0.5 – 0.75 mg/kg – max dose 3 mg/Kg – Infusion dose of 1-4 mg/min – Precautions: – Decreased LVH.
  • 35. Magnesium sulfate • Indication: hypomagnesaemia & Torsades de pointes. • Dose: • initial dose 1-2 gram iv push over 2 min • Infusion dose of 1 gram/hr • Precautions: • Hypotension. • Renal failure.
  • 36. Sodium bicarbonate • Indications – Pre-existing metabolic acidosis, –↑K – Prolonged arrest > 10 min • Dose: – 1 mEq / Kg • Precautions: – ↑ Na / Hyperosmolality – Metabolic alkalosis – Unfavorable shift of O2-Hb dissociation curve • Contraindication – hypoxic lactic acidosis
  • 37. Medications Medication 2005 changes Epinephrine •No change Vasopressin •All pulseless rhythms •Can be used in E.T.T Atropine •Maximum dose 3 mg Amiodarone •No changes Lidocaine •No changes
  • 38. References • Aung K, Htay T. Vasopressin for cardiac arrest: a systematic review and meta-analysis. Arch Intern Med 2005:17-24 • 2005 International Consensus Conference.Circulation 2005;112:III-29 • Linder KH, Strohmenger HU, Ensinger H, Hetzel WD, Ahnefeld FW, Georgieff M, Stress hormone response during and after cardiopulmonary resuscitation. Anesthesiology 1992;77:662-668 • Linder KH, Haak T, Keller A, Bothner U, Lurie KG, Release of endogenous vasopressors during and after cardiopulmonary resuscitation. Heart 1996;75:145-150 • Wenzel V, Linder KH, Augenstein S, Prengel AW, Strohmenger HU, Vasopressin combined with epinephrine decreases cerebral perfusion compared with vasopressin alone during cardiopulmonary resuscitation in pigs. Stroke. 1998;29:1462-1467: discussion 1467-1468. • Babar SI, Berg RA, Hilwig RW, Kern KB, Ewy GA Vasopressin versus epinephrine during CPR: a randomized swine outcome study. Resuscitation 1999; 185-192 • Linder KH, Dricks B, Strohmenger HU, Prengel AW, Lindner IM, Lurie KG, Randomized comparison of epinephrine and vasopressin in patients with out of hospital VF. Lancet. 1997; 349: 535-537
  • 39. References • Kudenchuk PJet al. Amiodarone for resuscitation after out-of-hospital cardiac arrest due to ventricular fibrillation. N Engl J Med. 1999:871-878 • Dorian P et al. Amiodarone as compared with lidocaine for shock-resistant ventricular fibrillation. N Engl J Med 2002:884-90 • 2005 International Consensus Conference.Circulation 2005;112:III-17 • Paul Dorian, et al. NEJM 2002 Amiodarone as Compared with Lidocaine for Shock-Resistant Ventricular Fibrillation
  • 40. ACLS Pulseless Arrest Algorithm
  • 41. Primary A,B,C,D
  • 42. Primary A,B,C,D
  • 43. Primary A,B,C,D
  • 44. Primary A,B,C,D
  • 45. Secondary A,B,C,D
  • 46. Secondary A,B,C,D
  • 47. Secondary A,B,C,D
  • 48. Secondary A,B,C,D
  • 49. Secondary A,B,C,D
  • 50. Secondary A,B,C,D
  • 51. • “Flat line” protocol: – Check leads attachment. – Check leads selection – Power on/off – Check the gain

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