GEMC- ACLS Overview: Pulseless Arrest- for Residents

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This is a lecture by Rockefeller Oteng from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.

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GEMC- ACLS Overview: Pulseless Arrest- for Residents

  1. 1. Project: Ghana Emergency Medicine Collaborative Document Title: ACLS Overview: Pulseless Arrest Author(s): Rockefeller Oteng (University of Michigan), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1  
  2. 2. Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt { Content the copyright holder, author, or law permits you to use, share and adapt. } Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Creative Commons – Zero Waiver Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Make Your Own Assessment { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ { Content Open.Michigan has used under a Fair Use determination. } Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. 2   To use this content you should do your own independent analysis to determine whether or not your use will be Fair.
  3. 3. PULSELESS ARREST -  Call for help, give CPR -  Give O2, attach monitor/defibrillator Shockable VF/VT 3 Give 1 shock, resume CPR immediately 1 Not Shockable -  Check rhythm -> SHOCKABLE rhythm? Asystole/PEA 9 4 2 - Resume CPR for 5 cycles - Options: epinephrine, vasopressin, atropine 5 cycles CPR Check if rhythm is SHOCKABLE? 5 cycles CPR 5 Check if rhythm is SHOCKABLE? 11 -  Give 1 shock, resume CPR immediately -  Options: epinephrine, vasopressin, atropine 6 5 cycles CPR Check if rhythm is SHOCKABLE? 10 Not Shockable 7 Shockable -  Continue CPR while defibrillator is charging -  Give 1 shock -  Resume CPR immediately after the shock -  Consider anti-arrhythmics e.g. amiodarone, lidocaine, etc -  Consider magnesium -  After 5 cycles CPR, go to Box 5 above -  If asystole, go to Box 10 -  If electrical activity, check pulse. No pulse, go to Box 10 -  If pulse present, begin post-resuscitation care 12 Not Shockable Shockable Go to Box 4 During CPR (abbreviated) -  Push hard and fast (100/min) -  Ensure full chest recoil -  Minimize interruptions in chest compressions 8 3   13
  4. 4. Full Guidelines for CPR in Pulseless Arrest Algorithm During CPR -  Push hard and fast (100/min) -  Ensure full chest recoil -  Minimize interruptions in chest compressions -  One cycle of CPR: 30 compressions + 2 breaths; 5 cycles, 2 mins -  Avoid hyperventilation -  Secure airway and confirm placement ** After advanced airway is placed, rescuers no longer deliver cycles of CPR. Give continuous chest compressions without pauses for breaths. Give 8-10 breaths/min. Check rhythm every 2 minutes. - Rotate compressors every 2 minutes with rhythm checks -  Search for and treat possible contributing factors -  HYPOVOLEMIA -  HYPOXIA -  HYDROGEN ION (ACIDOSIS) -  HYPO/HYPERKALEMIA -  HYPOGLYCEMIA -  HYPOTHERMIA -  TOXINS -  CARDIAC TAMPONADE -  TENSION PNEUMOTHORAX -  THROMBOSIS (CORONARY/PULMONARY) -  TRAUMA
  5. 5. PULSELESS ARREST -  BLS Algorithm: Call for help, give CPR -  Give O2 when available -  Attach monitor/defibrillator when available Shockable VF/VT 3 Glenlarson, Wikimedia Commons -  Check rhythm -> SHOCKABLE rhythm? 1 Not Shockable 2 Asystole/PEA Glenlarson, Wikimedia Commons 9 5  
  6. 6. 9 Asystole/PEA Not shockable -  Resume CPR immediately for 5 cycles -  Epinephrine, repeat every 3-5 min -  OR 1 dose of vasopressin -  OR consider atropine, repeat every 3-5 min 10 5 cycles CPR -  Check rhythm -> SHOCKABLE rhythm? 11 Glenlarson, Wikimedia Commons 6  
  7. 7. -  Resume CPR immediately for 5 cycles -  Epinephrine, repeat every 3-5 min -  OR 1 dose of vasopressin -  OR consider atropine, repeat every 3-5 min 10 5 cycles CPR -  Check rhythm -> SHOCKABLE rhythm? -  If asystole, go to Box 10 -  If electrical activity, check pulse. No pulse, go to Box 10 -  If pulse present, begin postresuscitation care Not Shockable Shockable 11 Go to Box 4 13 12 7  
  8. 8. PULSELESS ARREST -  Call for help, give CPR -  Give O2, attach monitor/defibrillator Shockable VF/VT 3 Give 1 shock, resume CPR immediately 1 Not Shockable -  Check rhythm -> SHOCKABLE rhythm? Asystole/PEA 9 4 2 - Resume CPR for 5 cycles - Options: epinephrine, vasopressin, atropine 5 cycles CPR Check if rhythm is SHOCKABLE? 5 cycles CPR 5 Check if rhythm is SHOCKABLE? 11 -  Give 1 shock, resume CPR immediately -  Options: epinephrine, vasopressin, atropine 6 5 cycles CPR Check if rhythm is SHOCKABLE? 10 Not Shockable 7 Shockable -  Continue CPR while defibrillator is charging -  Give 1 shock -  Resume CPR immediately after the shock -  Consider anti-arrhythmics e.g. amiodarone, lidocaine, etc -  Consider magnesium -  After 5 cycles CPR, go to Box 5 above -  If asystole, go to Box 10 -  If electrical activity, check pulse. No pulse, go to Box 10 -  If pulse present, begin post-resuscitation care 12 Not Shockable Shockable Go to Box 4 During CPR -  Push hard and fast (100/min) -  Ensure full chest recoil -  Minimize interruptions in chest compressions 8 8   13
  9. 9. -  Continue CPR while defibrillator is charging -  Give 1 shock -  Resume CPR immediately after the shock -  Epinephrine, repeat every 3-5 min -  OR 1 dose of vasopressin 6 5 cycles CPR Not Shockable -  Check rhythm -> SHOCKABLE rhythm? 7 -  If asystole, go to Box 10 -  If electrical activity, check pulse. No pulse, go to Box 10 -  If pulse present, begin postresuscitation care 12 Shockable -  Continue CPR while defibrillator is 8 charging -  Give 1 shock -  Resume CPR immediately after the shock -  Consider anti-arrhythmics e.g. amiodarone, lidocaine, etc -  Consider magnesium -  After 5 cycles CPR, go to Box 5 above
  10. 10. Shockable 3 VF/VT -  Give 1 shock -  Resume CPR immediately after the shock 4 5 cycles CPR -  Check rhythm -> SHOCKABLE rhythm? 5
  11. 11. Wide  Complex  Tachycardia   •  •  •  DDx: –  Ventricular Tachycardia (VT) –  SVT w/ BBB (often rate dependent) –  SVT w/ atrioventricular conduction via accessory pathway How to differentiate: –  Concordance in leads V1-V6 –  RS >100 ms in the precordial leads –  AV disassociation When in doubt treat as VT 11  
  12. 12. V  Tach   Ksheka, Wikimedia Commons 12  
  13. 13. V  Fib   Jer5150, Wikimedia Commons 13  
  14. 14. Wide  Complex  Tachycardia   •  •  Stable –  Amiodarone 150 mg over 10 min or other antiarrhythmic –  Prepare for synchronized cardioversion Unstable –  ABC’s/Call for help/Start CPR –  Defibrillate: Biphasic 120-200 J (When in doubt pick 200 J), monophasic 360 J –  Epinephrine 1 mg IV q3-5 min –  Vasopressin 40 Units IV –  May try amiodarone or lidocaine after 3 attempts at defibrillation •  Amiodarone 300 mg, may repeat w/ 150 mg x1 •  Lidocaine 1-1.5 mg/kg, then 0.5-0.75 mg/kg, max is 3 mg/kg 14  
  15. 15. -  Continue CPR while defibrillator is charging -  Give 1 shock -  Resume CPR immediately after the shock -  Epinephrine, repeat every 3-5 min -  OR 1 dose of vasopressin 6 5 cycles CPR -  Check rhythm -> SHOCKABLE rhythm? 7 Not Shockable -  If asystole, go to Box 10 -  If electrical activity, check pulse. No pulse, go to Box 10 -  If pulse present, begin postresuscitation care 12 Shockable -  Continue CPR while defibrillator is 8 charging -  Give 1 shock -  Resume CPR immediately after the shock -  Consider anti-arrhythmics e.g. amiodarone, lidocaine, etc -  Consider magnesium -  After 5 cycles CPR, go to Box 5 above
  16. 16. torsades  de  pointes   Jer5150, Wikimedia Commons 16  
  17. 17. Pulseless  Arrest   4  Basic  Rhythms   Shockable    V-­‐fib    V-­‐Tach   Non-­‐Shockable    Asystole    PEA   17  
  18. 18. Shockable  Rhythms   •  Ventricular  Tachycardia   •  V-­‐Fib   –  Shock  early   –  ABC’s   •  Tx  of  VT/VF   –  –  –  –  –  –  –  –  –  –  Shock-­‐  biphasic  200j,  monophasic  360j  (one  x)   CPR-­‐IV,  ETT   Shock   CPR-­‐epi/vasopressin   Shock   CPR-­‐Lido/amiodarone   Shock   CPR-­‐epi   Shock   CPR-­‐  lido/amio   18  
  19. 19. NON-­‐Shockable   •  PEA   •  Asystole   •  Tx  of  Asystole  &  PEA   –  CPR-­‐IV,airway   –  Meds-­‐vasopressin/epi   –  CPR-­‐2  min   –  Meds-­‐epi,atropine*   –  CPR   –  Meds-­‐epi,atro   –  CPR   –  *Atropine  used  in  PEA,  only  for  HR  <  60   19  
  20. 20. Tachycardia’s   Stable  vs.  Unstable   •  Stable   – MI   – 12  lead   – Narrow  complex   – Wide  complex   – Treat  causes   •  Unstable   – Altered  MS   – CP   – Hypotension   – Signs  of  shock   •  H’s  and  T’s   20  
  21. 21. Contribuang  Factors     H’s  and  T’s   •  •  •  •  •  •  •  •  •  •  •  Hypovolemia   Hypoxia   Hydrogen  ion  (acidosis)   Hypo/hyperkalemia   Hypoglycemia   Hypothermia   Toxins  (drugs)   Tamponade  (cardiac)   Tension  PTX   Thrombosis  (coronary  or  pulmonary)   Trauma   21  
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