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ACLS - update and review

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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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