ACLS - update and review

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  • Patients who do not respond to a total dose of 5 to 10 mg should undergo evaluation for alternative causes of encephalopathy.DDx: opiod intox, NMS, serotonin syndrome less likely (Afebrile), hypoglycemia, COPD exac?
  • Although no published human or animal evidencedemonstrates that starting CPR with 30 compressionsrather than 2 ventilations leads to improved outcome, chestcompressions provide the blood flow, and studies of out-ofhospitaladult cardiac arrest showed that survival was higherwhen bystanders provided chest compressions rather than nochest compressions.
  • In most studies, delivery of more compressions during resuscitation is associated with better survival, and delivery of fewer compressions is associated with lower survival.
  • The total number of compressions delivered during resuscitationis an important determinant of survival from cardiac arrest.The number of compressions delivered is affected by thecompression rate and by the compression fraction (the portionof total CPR time during which compressions are performed)
  • When any rescuer witnesses an out-of-hospital arrest and an AED is immediately available on-site, the rescuer should start CPR with chest compressions and use the AED as soon as possible. Healthcare providers who treat cardiac arrest in hospitals and other facilities with on-site AEDs or defibrillators should provide immediate CPR and should use the AED/defibrillator as soon as it is available. These recommendations are designed to support early CPR and early defibrillation, particularly when an AED or defibrillator is available within moments of the onset of sudden cardiac arrest. When an out-of-hospital cardiac arrest is not witnessed by EMS personnel, EMS may initiate CPR while checking the rhythm with the AED or on the electrocardiogram (ECG) and preparing for defibrillation. In such instances, 1.to 3 minutes of CPR may be considered before attempted defibrillation. Whenever 2 or more rescuers are present, CPRshould be provided while the defibrillator is retrieved.With in-hospital sudden cardiac arrest, there is insufficient evidence to support or refute CPR before defibrillation.However, in monitored patients, the time from VF to shock delivery should be under 3 minutes, and CPR should beperformed while the defibrillator is readied.When VF is present for more than a few minutes, the myocardium is depleted of oxygen and energy. A brief periodof chest compressions can deliver oxygen and energy to the heart, increasing the likelihood that a shock will both eliminate VF (defibrillation) and be followed by ROSC. Before the publication of the 2005 AHA Guidelines for CPR and ECC, 2 studies suggested the potential benefit of CPR first rather than shock first. In both studies, although 1. to 3 minutes of CPR before shock delivery did not improve overall survival from VF, the CPR-first strategy did improve survival among victims with VF if the EMS call-to-arrival interval was 4 to 5 minutes or longer. However, 2 subsequent randomized controlled trials found that CPR before attempted defibrillation by EMS personnel was not associated with a significant difference in survival to discharge. One retrospective study did find an improved neurologic status at 30 days and at 1 year when immediate CPR was compared with immediate defibrillation in patients with out-of-hospital VF.
  • Adult stable monomorphic VT responds well tomonophasic or biphasic waveform cardioversion (synchronized)shocks at initial energies of 100 J. If there is no response to thefirst shock, it may be reasonable to increase the dose in a stepwisefashion.Synchronized cardioversion must not be used for treatmentof VF because the device is unlikely to sense a QRS wave,and thus, a shock may not be delivered.When VF is present for more than afew minutes, the myocardium is depleted of oxygen andmetabolic substrates. A brief period of chest compressionscan deliver oxygen and energy substrates and “unload” thevolume-overloaded right ventricle, increasing the likelihoodthat a perfusing rhythm will return after shockdelivery.
  • Adult stable monomorphic VT responds well tomonophasic or biphasic waveform cardioversion (synchronized)shocks at initial energies of 100 J. If there is no response to thefirst shock, it may be reasonable to increase the dose in a stepwisefashion.Synchronized cardioversion must not be used for treatmentof VF because the device is unlikely to sense a QRS wave,and thus, a shock may not be delivered.When VF is present for more than afew minutes, the myocardium is depleted of oxygen andmetabolic substrates. A brief period of chest compressionscan deliver oxygen and energy substrates and “unload” thevolume-overloaded right ventricle, increasing the likelihoodthat a perfusing rhythm will return after shockdelivery.
  • Unstable polymorphic ventricular tachycardia is treated with unsynchronized shocks (defibrillation). Defibrillation is used because synchronization is not possible.Synchronized cardioversion must not be used for treatmentof VF because the device is unlikely to sense a QRS wave,and thus, a shock may not be delivered.
  • Studies of waveform capnography to verify endotracheal tube position in victims of cardiac arrest have shown 100% sensitivity and 100% specificity in identifying correct endotracheal tube placement.During untreated cardiac arrest CO2 continues to be produced in the body, but there is no CO2 delivery to thelungs. Under these conditions PETCO2 will approach zero with continued ventilation. With initiation of CPR, cardiacoutput is the major determinant of CO2 delivery to the lungs. If ventilation is relatively constant, PETCO2 correlates well with cardiac output during CPR.
  • Quantitative waveform capnography is recommended for confirmation and monitoring of endotracheal tube placementand CPR quality.
  • There is no definitiveclinical evidence that early intubation or drug therapy improvesneurologically intact survival to hospital discharge.
  • If IV or IO access cannot be established, epinephrine,vasopressin, and lidocaine may be administered by theendotracheal route during cardiac arrest (Class IIb, LOE B).The optimal endotracheal dose of most drugs is unknown, buttypically the dose given by the endotracheal route is 2 to 21⁄2times the recommended IV dose.Providers should dilute the recommended dose in 5 to 10 mLof sterile water or normal saline and inject the drug directlyinto the endotracheal tube.256 Studies with epinephrine263 andlidocaine251 showed that dilution with sterile water instead of0.9% saline may achieve better drug absorption.
  • Since 2005, two nonrandomized studies with concurrentcontrols and other studies using historic controls haveindicated the possible benefit of therapeutic hypothermiaafter in-hospital cardiac arrest and out-of-hospital cardiacarrest with PEA/asystole as the presenting rhythm.As noted above, an oxygen saturation of 100% maycorrespond to a Pao2 anywhere between approximately 80 and500 mm Hg.
  • Bicarbonate may compromise CPP by reducing systemic vascular resistance.313 It can create extracellular alkalosisthat will shift the oxyhemoglobin saturation curve and inhibit oxygen release. It can produce hypernatremia andtherefore hyperosmolarity. It produces excess CO2, which freely diffuses into myocardial and cerebral cells and mayparadoxically contribute to intracellular acidosis.314 It can exacerbate central venous acidosis and may inactivate simultaneously administered catecholamines.In some special resuscitation situations, such as preexisting metabolic acidosis, hyperkalemia, or tricyclic antidepressant overdose, bicarbonate can be beneficial
  • Lim SH et al. Comparison of treatment of supraventricular tachycardia by Valsalva maneuver and carotid sinus massage. Ann Emerg Med 1998 Jan 31 30 35 Conversion rate of up to 28% with nonpharmacologic therapy
  • Lim SH et al. Comparison of treatment of supraventricular tachycardia by Valsalva maneuver and carotid sinus massage. Ann Emerg Med 1998 Jan 31 30 35 Conversion rate of up to 28% with nonpharmacologic therapy
  • Adenosine is recommended in the initial diagnosisand treatment of stable, undifferentiated regular, monomorphicwide-complex tachycardia (this is also consistent in ACLS andPALS recommendations). It is important to note that adenosineshould not be used for irregular wide-complex tachycardiasbecause it may cause degeneration of the rhythm to VF.
  • The heart fills during diastole, and diastole is normally 2/3 the cardiac cycle. A rapid heart rate will significantly reduce the time which the ventricles have to fill. The reduced filling time results in a smaller amount of blood ejected from the heart during systole. The end result is a drop in cardiac output & hypotension.Unstable patients with SVT and a pulse are always treated with cardioversion
  • The 4 most common types of SVT are A-V Nodal Reentry Tachycardia, A-VReentry Tachycardia, atrial tachycardia and atrial flutter. These rhythmsare regular in nature and have a rate > 150. To distinguish the differencebetween the re-entry tachycardias and the other types really requires a 12lead ECG. The diagnostic criteria to determine that it is a reentranttachycardia is actually quite complex.
  • pulseless ventricular tachycardia.
  • ACLS - update and review

    1. 1. ACLS Update and Review Dwight Owen Stephanie Tang Leticia Varella
    2. 2. Case  62 yo man with met CRPC with diffuse bone     metastases s/p multiple radiation treatments with refractory pain Admitted with back pain for r/o spinal cord compression Could not tolerate MRI  CT instead without obvious compression Given steroids with PPI, DVT ppx Home methadone continued during admission for pain control, lexapro for depression, albuterol prn for SOB (former smoker, ? Mild COPD)
    3. 3. Morning Sign Out  Overnight, patient again failed to tolerate MRI despite pre-medication with ativan and methadone PCA  Was agitated and aggressive, but afebrile with other VSS, haldol x 1 given in MRI suite
    4. 4. Morning Rounds  When you round on the patient in the morning, he is unresponsive.
    5. 5. Vitals  HR 96  BP 90/60  RR 6  S02 88%  Afebrile  BG: 60  Pinpoint pupils, no wheezing, moving ext x 4  Naloxone 0.4 mg x1 given without improvement
    6. 6. Lab from yesterday  CBC: Hgb 8.9 (baseline)  BMP: 140/4.2  Phos 2.5  Mg 1.1 106/33 29/1.4 < 71
    7. 7.  Biphasic unsynchronized shock (ie defibrillation) delivered at 200J  Next step?  ROSC obtained during next rhythm check  Still not following commands
    8. 8. BLS: Because you don’t always have a code cart
    9. 9. BLS  No more “look, listen, and feel.”  Continued emphasis has been placed on high- quality CPR  chest compressions of adequate rate and depth  allowing complete chest recoil after each compression  minimizing interruptions in compressions  avoiding excessive ventilation
    10. 10. BLS  There has been a change in the recommended sequence for the lone rescuer to initiate chest compressions before giving rescue breaths (C-A-B rather than A-B-C). The lone rescuer should begin CPR with 30 compressions rather than 2 ventilations to reduce delay to first compression.  Compression rate should be at least 100/min (rather than “approximately” 100/min).  Compression depth for adults has been changed from the range of 1 to 2 inches to at least 2 inches (5 cm).
    11. 11. AED
    12. 12. AED  Shock First vs CPR First  1-Shock Protocol vs 3-Shock Sequence (no stacking)  Defibrillation Waveforms and Energy Levels (Biphasic > Monophasic)  Synchronized Cardioversion  Afib: Biphasic 120-200J  Aflutter Biphasic 100 J  If first attempt fails, increase dose incrementally
    13. 13. Synchronized Cardioversion  Unstable SVT  Unstable atrial fibrillation  Unstable atrial flutter  Unstable monomorphic (regular) VT  Synchronization avoids shock delivery during the relative refractory period of the cardiac cycle when a shock could produce VF
    14. 14. Synchronized vs Unsynchronized  If there is any doubt whether monomorphic or polymorphic VT is present in the unstable patient, do not delay shock delivery to perform detailed rhythm analysis: provide high-energy unsynchronized shocks (ie, defibrillation doses).
    15. 15. Treatment? With a pulse Adult stable monomorphic VT responds well to monophasic or biphasic waveform cardioversion (synchronized) shocks at initial energies of 100 J. If there is no response to the first shock, it may be reasonable to increase the dose in a stepwise fashion.
    16. 16. Treatment? Without a pulse Pulseless arrest algorithm
    17. 17. Treatment? SBP 150 SBP 70 Unstable polymorphic ventricular tachycardia is treated with unsynchronized shocks (defibrillation). Defibrillation is used because synchronization is not possible.
    18. 18. The wave of the future
    19. 19. With initiation of CPR, cardiac output is the major determinant of CO2 delivery to the lungs 100% sensitivity and 100% specificity in identifying correct endotracheal tube placement.
    20. 20. 40 mmHg 15 mmHg
    21. 21. High Quality CPR  Maintain 30:2 ratio until advanced airway  Minimize interruptions in CPR  De-emphasis on Devices, Drugs, and Distractions  Allow complete chest recoil after each compression  Rate of at least 100 compressions/min
    22. 22. Medications  Atropine is no longer part of pulseless arrest algorithm  Central line ideal, however should not delay time to CPR or meds  IO if two failed attempts at IV  ETT?
    23. 23. What medications can be absorbed through the trachea?  Lidocaine  Epinephrine  Atropine  Naloxone  Vasopressin
    24. 24. Post Cardiac-Arrest Care  Hypothermia protocol  Taper Fi02 to keep Sa02 > 94%  Identify and treat ACS and other reversible causes  Anticipate, treat, and prevent multiple organ dysfunction. This includes avoiding excessive ventilation and hyperoxia.  Transport/transfer to an appropriate hospital or critical care unit with a comprehensive post– cardiac arrest treatment system of care
    25. 25. Medications not generally recommended during cardiac arrest  Atropine  Sodium Bicarbonate  Calcium  Fibrinolysis ?
    26. 26. Mega-code  A 40 year old man arrives at the ER accompanied by his family. He is complaining of palpitations after working outside for several hours. The assessment is as follows:  SKIN: pale, warm and dry CVS: Strong peripheral pulses and a BP of 125/80 CNS: Fully intact RESP: RR is 22, no resp. distress, lungs CTA  An EKG is obtained
    27. 27. What is the next appropriate intervention? A – Adenosine 6 mg IVP through closest line to the heart followed by 20 ml NS push B – Attempt vagal maneuvers C – Perform synchronized cardioversion D – Give epinephrine 1 mg IVP
    28. 28. What is the next appropriate intervention? A – Adenosine 6 mg IVP through closest line to the heart followed by 20 ml NS push B – Attempt vagal maneuvers C – Perform synchronized cardioversion D – Give epinephrine 1 mg IVP Lim SH et al. Comparison of treatment of supraventricular tachycardia by Valsalva maneuver and carotid sinus massage. Ann Emerg Med 1998 Jan 31 30 35
    29. 29. You have performed vagal maneuvers and there is no change in the patient’s heart rate and rhythm. What is your next step?  A - Give adenosine 6mg rapid IV push. If no conversion, give 12mg rapid IV push  B - Give adenosine 12mg rapid IV push. If no conversion, give another 12mg rapid IV push  C - Give Amiodarone 150mg over 10 minutes. May repeat as needed  D - Continue to attempt vagal manuvers until the patient converts to a regular sinus rhythm
    30. 30. You have performed vagal maneuvers and there is no change in the patients heart rate and rhythm. What is your next step?  A - Give adenosine 6mg rapid IV push. If no conversion, give 12mg rapid IV push  B - Give adenosine 12mg rapid IV push. If no conversion, give another 12mg rapid IV push  C - Give Amiodarone 150mg over 10 minutes. May repeat as needed  D - Continue to attempt vagal manuvers until the patient converts to a regular sinus rhythm
    31. 31. You give 6mg Adenosine rapid IV push with no effect. 12mg Adenosine rapid IV push is then given. The patient develops severe ongoing chest pain and his vital signs are: HR 220, BP (not obtainable), and weak pulse. Your next step should be.  A – Immediate defibrillation  B – Give 2nd dose of adenosine rapid IVP  C – Perform immediate synchronized cardioversion  D – Perform precordial thump
    32. 32. You give 6mg Adenosine rapid IV push with no effect. 12mg Adenosine rapid IV push is then given. The patient develops severe ongoing chest pain and his vital signs are: HR 220, BP (not obtainable), and weak pulse. Your next step should be.  A – Immediate defibrillation  B – Give 2nd dose of adenosine rapid IVP  C – Perform immediate synchronized cardioversion  D – Perform precordial thump
    33. 33. Stable or Unstable SVT?  Shortness of breath  Palpitation feeling in chest  Ongoing chest pain  Dizziness  Rapid breathing  Loss of consciousness  Numbness of body parts
    34. 34. Stable or Unstable SVT?  Shortness of breath  Palpitation feeling in chest  Ongoing chest pain  Dizziness  Rapid breathing  Loss of consciousness  Numbness of body parts Unstable patients with SVT and a pulse are always treated with cardioversion
    35. 35. After synchronized cardioversion is unsuccessful, the pt. continues to deteriorate. The patient is now unconscious. No pulse is palpable. Below is what you see on the monitor: What is your first intervention: A – Deliver 2 minutes of CPR and then re-assess rhythm B – Give epinephrine 1 mg IV push and repeat every 3-5 minutes C – Give one unsynchronized shock (120-200 J) D – Place an advanced airway
    36. 36. After synchronized cardioversion is unsuccessful, the pt. continues to deteriorate. The patient is now unconscious. No pulse is palpable. Below is what you see on the monitor: What is your first intervention: A – Deliver 2 minutes of CPR and then re-assess rhythm B – Give epinephrine 1 mg IV push and repeat every 3-5 minutes C – Give one unsynchronized shock (120-200 J) D – Place an advanced airway
    37. 37. The patient does not respond to the defibrillation with 120 J. He remains unconscious in ventricular tachycardia. What is your next intervention?  A – Deliver up to two additional shocks of 200 J  B – Give 1 mg epinephrine IV push and repeat q3-5 min  C – Give 2 minutes of CPR  D – Check the rhythm and the pulse
    38. 38. The patient does not respond to the defibrillation with 120 J. He remains unconscious in ventricular tachycardia. What is your next intervention?  A – Deliver up to two additional shocks of 200 J  B – Give 1 mg epinephrine IV push and repeat q3-5 min  C – Give 2 minutes of CPR  D – Check the rhythm and the pulse
    39. 39. After completing 2 minutes of CPR, your rhythm check indicates a second shock. You shock a second time with 160 J, and the patient's rhythm does not change. You resume CPR. While completing the cycle of CPR what else should be done?  A – Epinephrine 1 mg IVP q3-5 min  B – Vasopressin 40 mg IVP to replace first or second dose of epinephrine  C – Epinephrine 0.5 mg q3-5 min  D – Both A and B
    40. 40. After completing 2 minutes of CPR, your rhythm check indicates a second shock. You shock a second time with 160 J, and the patient's rhythm does not change. You resume CPR. While completing the cycle of CPR what else should be done?  A – Epinephrine 1 mg IVP q3-5 min  B – Vasopressin 40 mg IVP to replace first or second dose of epinephrine  C – Epinephrine 0.5 mg q3-5 min  D – Both A and B
    41. 41. You have given the epinephrine or vasopressin and completed the 5 cycles of CPR. A rhythm check reveals no change. You attempt at third defibrillation. What will be your defibrillator setting? (assume biphasic)  A – 160 J  B – 200 J  C – 300 J  D – 360 J
    42. 42. You have given the epinephrine or vasopressin and completed the 5 cycles of CPR. A rhythm check reveals no change. You attempt at third defibrillation. What will be your defibrillator setting? (assume biphasic)  A – 160 J  B – 200 J  C – 300 J  D – 360 J
    43. 43. The third shock does not change the rhythm and you restart CPR. You have shocked, you have given vasopressors (epinephrine and/or vasopressin), you have continued with effective CPR. What medication should be considered at this point?  A – Atropine  B – Adenosine  C – Amiodarone  D – Amiloride
    44. 44. The third shock does not change the rhythm and you restart CPR. You have shocked, you have given vasopressors (epinephrine and/or vasopressin), you have continued with effective CPR. What medication should be considered at this point?  A – Atropine  B – Adenosine  C – Amiodarone  D – Amiloride
    45. 45. What is the correct dosing for amiodarone in the Pulseless Arrest Algorithm?  A – 150 mg IV once, if not effective may give one additional dose of 300 mg IV  B – 200 mg IV once  C – 300 mg IV once, may be repeated with 150 mg IV one additional time  D – Infusion of 300 mg IVPB in one hour
    46. 46. What is the correct dosing for amiodarone in the Pulseless Arrest Algorithm?  A – 150 mg IV once, if not effective may give one additional dose of 300 mg IV  B – 200 mg IV once  C – 300 mg IV once, may be repeated with 150 mg IV one additional time  D – Infusion of 300 mg IVPB in one hour
    47. 47. Amiodarone  Ca Channels  Na Channels  K Channels  Alpha-adrenergic  Beta-Adrenergic  Refractory VF/Pulseless VT
    48. 48. In addition to amiodarone, what other antiarrhythmic can you consider as part of the pulseless arrest algorithm?  A – Labetalol  B – Lidocaine  C – Digoxin  D - Flecainide
    49. 49. In addition to amiodarone, what other anti-arrythmic can you consider as part of the pulseless arrest algorithm?  A – Labetalol  B – Lidocaine  C – Digoxin  D - Flecainide
    50. 50. Great Job! You saved the patient He has been stabilized and intubated, but does not respond to verbal commands. He is transported to the hospital's ICU. Since the patient is not responsive what would be the most important intervention in the post-cardiac arrest phase?  A – Monitor waveform capnography  B – Obtain ABG  C – Induce therapeutic hypothermia  D – Monitor oxygen saturation
    51. 51. Great Job! You saved the patient He has been stabilized and intubated, but does not respond to verbal commands. He is transported to the hospital's ICU. Since the patient is not responsive what would be the most important intervention in the post-cardiac arrest phase?  A – Monitor waveform capnography  B – Obtain ABG  C – Induce therapeutic hypothermia  D – Monitor oxygen saturation
    52. 52. Possible Exclusion Criteria  Coma from other cause besides cardiac (toxins, CNS)  Known bleeding diathesis / ongoing bleeding +/- recent surgery  Sepsis  Ongoing shock with SBP < 90

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