Download ACLS Pharmacology/Algorithms Algorithms Primary ABCD Survey

ACLS
Pharmacology/Algorithms
Kristin Engebretsen, PharmD, CSPI
Clinical Toxicologist
Emergency Department
Regions Hospital, St. Paul, MN
Algorithms
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Cardiac Arrest
PEA
Asystole
Bradycardia
Tachycardia
„ SVT
„ Atrial fibrillation/Atrial Flutter
„ Wide complex tachycardia-unknown type
Ventricular arrhythmias
„ Ventricular Tachycardia
„ Ventricular Fibrillation
„ Torsades de Pointes (polymorphic VT)
Secondary ABCD Survey
A = Airway: place airway device as soon as possible
B = Breathing: confirm proper placement by PE
B = Breathing: confirm proper placement by 2nd
method
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End-tidal CO2 and/or
Esophageal detector devices
B = Breathing: prevent airway device dislodgment:
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Use purpose-made tube holder
Proven tape-and-tie or other technique
B = Breathing: monitor oxygenation and ventilation
Primary ABCD Survey
Focus: Basic CPR and
Defibrillation
A = Airway: open the airway
B = Breathing: check breathing,
provide positive-pressure
ventilations
C = Circulation: check circulation,
give chest compressions
D = Defibrillation: assess for and
shock VF/pulseless VT
Secondary ABCD Survey (cont’d)
C = Circulation: establish IV access
C = Circulation: identify rhythm
C = Circulation: give rhythm- and
condition-appropriate drugs
D = Differential Diagnosis: search
for and treat identified reversible
causes
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Background:
Defibrillation and Time
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Approximately 50% survival after 5 minutes
Survival reduced by 7% to 10% per minute (if no
CPR)
Rapid defibrillation is key
CPR prolongs VF, slows deterioration
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Probability of Survival Is Related to 2 Intervals:
(1) Collapse to Defibrillation and (2) Collapse to CPR
Collapse to start of CPR: 1, 5, 10, 15 (min)
Probability
of survival to
hospital
discharge
80
60
Survival
40
Minutes: collapse to 1st shock
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Collapse to defibrillation interval (min)
0
1
3
6
10
Probability of Survival Is Related to 2 Intervals:
(1) Collapse to Defibrillation and (2) Collapse to CPR
(cont’d)
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Graph displays probability of survival to
hospital discharge in relation to interval to
defibrillation
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For 4 given intervals: collapse to start of CPR
(1, 5, 10, 15 min)
Example:
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Determining Which Nomogram
to Use?
If time to defibrillation = 10 min and time to
CPR = 5 min, probability of survival = 18%
Data from
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King County, WA (n=1667 witnessed VF arrests)1
Additional cases (n=205) from Tucson, AZ2
1Eisenberg et al. Ann Emerg Med. 1993;22:1652-1658.
2Valenzuela et al. Circulation. 1997;96:3308-3313.
MNEMONICS: Bradycardia
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All Trained Dogs Eat Iams
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MNEMONICS:
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Asystole: TEA
Bradycardia: All Trained Dogs Eat Iams
Synchronized Cardioversion: Oh Say It
Isn’t So
PEA: PEA (5H, 5T)
Pulseless Vtach/Vfib: Please Shock
Shock Shock, EVerybody Shock And
Lets Make People Better.
Asystole
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Check responsiveness
Airway
Breathing
Circulations
Confirm in 2 or more
leads
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MNEMONICS: ASYSTOLE
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TEA
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Transcutaneous pacing
Epinephrine
Atropine
Transcutaneous pacing
EpinephrineAtropine
MNEMONICS: PEA
PEA
Problem
Epi
Atropine
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(5H and 5T)
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Hypovolemia
Hypoxia
Hydrogen Ion (acidosis)
Hypothermia
Tablets
Toxins/overdose
Tamponade, cardiac
Tension Pneumothorax
Thrombosis-coronary
Thrombosis-pulmonary
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Classify Specific Tachycardia
1.
2.
Atrial fibrillation/flutter
Narrow-complex tachycardias
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3.
Wide-complex tachycardia of unknown type
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Paroxysmal supraventricular tachycardia (PSVT)
Junctional tachycardia
Multifocal atrial or ectopic atrial tachycardia
Wide-complex tachycardia—not specified
Aberrant conduction of an SVT
Ventricular tachycardia
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Stable monomorphic VT
Stable polymorphic VT (baseline QT interval normal)
Stable polymorphic VT (baseline QT interval prolonged =
torsades de pointes
MNEMONICS: Synchronized
Cardioversion:
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Oh Say It Isn’t So
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O2 saturation monitor
Suction equipment
IV line
Intubation equipment
Sedation and analgesics
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4. Stable Monomorphic/
Polymorphic VT
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Monomorphic VT: is cardiac function impaired?
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Preserved: procainamide
Impaired: amiodarone OR lidocaine OR
synchronized cardioversion
Polymorphic VT: QT interval (baseline) prolonged?
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Wide-Complex Tachycardia
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Ventricular or
Supraventricular with aberrant
conduction?
Normal: treat ischemia, correct electrolytes (amiodarone or
lidocaine if heart impaired)
Prolonged: correct electrolytes
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Magnesium, overdrive pacing, isoproterenol,
dilantin, lidocaine
Ventricular Tachycardia
Ventricular Fibrillation
MNEMONICS: Pulseless
Vtach/Vfib:
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Shock Shock Shock (200J, 300J, 360J)
Everybody-Epinephrine or Vasopressin
Shock-(360J)
And-Amiodarone
Lets-Lidocaine
Make-Magnesium
People -Procainamide
Better-Bicarbonate
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VF/Pulseless VT
VF/Pulseless VT (cont’d)
Primary ABCD Survey
Focus: basic CPR and defibrillation
A
B
C
D
• Check responsiveness
• Activate emergency response system
• Call for defibrillator
Airway: open the airway
Breathing: provide positive-pressure ventilations
Circulation: give chest compressions
Defibrillation: assess for and shock VF/pulseless VT, up to 3 times
(200 J, 200 to 300 J, 360 J, or equivalent biphasic) if necessary
Rhythm after first 3 shocks?
Shock-Resistant VF/Pulseless VT
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Does patient show persistent or recurrent
VF/VT?
After IV is started: vasopressin or
epinephrine?
Consider antiarrhythmics: use amiodarone?
lidocaine? procainamide? magnesium?
Persistent or recurrent VF/VT
Secondary ABCD Survey
Focus: more advanced assessments and treatments
A
B
B
B
C
C
C
D
Airway: place airway device as soon as possible
Breathing: confirm airway device placement by exam plus confirmation device
Breathing: secure airway device; purpose-made tube holders preferred
Breathing: confirm effective oxygenation and ventilation
Circulation: establish IV access
Circulation: identify rhythm → monitor
Circulation: administer drugs appropriate for rhythm and condition
Differential Diagnosis: search for and treat identified reversible causes
VF/Pulseless VT (cont’d)
?
• Epinephrine 1 mg IV push, repeat every 3 to 5 minutes
or
• Vasopressin 40 U IV, single dose, 1 time only
Resume attempts to defibrillate
1 x 360 J (or equivalent biphasic) within 30 to 60 seconds
Consider antiarrhythmics:
• Amiodarone (llb for persistent or recurrent VF/pulseless VT)
• Lidocaine (Indeterminate for persistent or recurrent VF/pulseless VT)
• Magnesium (llb if known hypomagnesemic state)
• Procainamide (Indeterminate for persistent VF/pulseless VT;
llb for recurrent VF/pulseless VT)
Resume attempts to defibrillate
VF/Pulseless VT:
VF/Pulseless VT (cont’d)
• Epinephrine 1 mg IV push, repeat every 3 to 5 minutes
or
• Vasopressin 40 U IV, single dose, 1 time only
?
Resume attempts to defibrillate
1 x 360 J (or equivalent biphasic) within 30 to 60 seconds
Consider antiarrhythmics:
• Amiodarone (llb for persistent or recurrent VF/pulseless VT)
• Lidocaine (Indeterminate for persistent or recurrent VF/pulseless VT)
• Magnesium (llb if known hypomagnesemic state)
• Procainamide (Indeterminate for persistent VF/pulseless VT;
llb for recurrent VF/pulseless VT)
Resume attempts to defibrillate
Return of Spontaneous Circulation
Let Secondary ABCD Survey Guide
Postresuscitation Care
A = maintain open, protected airway
A = stabilize airway devices during transport;
avoid dislodgment
B = monitor ventilation (CO2) and oxygenation (O2)
C = monitor rhythm; give rhythm-appropriate medications
D = if defibrillation occurred after use of antiarrhythmic
agent, then continue maintenance infusion of
same agent
C = to maintain BP and HR: use dopamine or dobutamine
(avoid epinephrine, isoproterenol, norepinephrine)
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Background:
VF and Defibrillation
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VF: rhythm causing “all” sudden cardiac arrest
VF: useless quivering of heart → no blood flow
VF treatment: only one therapy works →
defibrillation
Defibrillation success: chances drop every minute
Stay Cool After Cardiac Arrest
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Mild Therapeutic Hypothermia to improve Outcome after
Cardiac Arrest (NEJM)
Treatment of Comatose Survivors of Out of Hospital Cardiac
Arrest with Induced Hypothermia (NEJM)
Induction of mild to moderate hypothermia after v-fib
cardiac arrest-increased the rate of favorable neurological
outcome and reduced mortality.
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Breaking News
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Stay Cool in Cardiac Arrest
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Arrhythmias
Increased risk of infection
Coagulopathy
Trauma (not shown to be effective)
MOA for Beneficial Effects:
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55% of the hypothermic had a favorable neurological outcome vs
39% of the normothermic in study 1; Study 2: 49% of the
hypothermic tx patients survived and had a good outcome
compared to 26% of the normothermic patients
Adverse Effects of
Hypothermia
If you come in Cold and Dead-Must
first Warm the patient, before you
can proclaim them dead
However, now if someone comes in
dead (cardiac arrest) and warm, you
need to cool them.
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Hypothermia reduces cerebral oxygen
consumption by 6% for every 1C reduction in
brain temperature >28C
Reduces abnormal electrical activity
Suppresses chemical reactions associated with
reperfusion injury (free radicals, calcium shifts etclead to mitochondrial damage)
Reduction of acidosis
Inhibition of the biosynthesis, release and uptake
of excitatory amino acids.
Hypothermia-How do you do
it?
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Cool to a core temperature of 32-34C.
Temperatures are monitored by bladder
temperature with a bladder temp probe.
May use ice pack method, cool saline method
or cooling blanket method.
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Ice Packs: apply ice packs around head, neck,
torso and limbs. When core temp reaches 33C
remove packs.
IV infusion of 30ml/kg of NS cooled to 4C over 30
minutes
Cooling blankets not available here, didn’t work as
well.
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Other Considerations
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Don’t drop temperature too quickly or below 32C as you
may induce a dysrhythmia or pulmonary edema
Hypothermia should be maintained for 12-24 hours.
Cooling should be started as soon as possible after ROSC,
but appears to be successful even if delayed for 4-6 hours.
Hypothermia would be expected to prevent an unfavorable
neurological outcome in less than 1 out of 13 patients.
Compared to asa for MI- 1 out of 70 patients benefit.
Case 3
Ventricular Tachycardia
A 60-year-old ECG technician collapses
while attaching a 12-lead ECG to a
patient. The technician has not
complained of discomfort before her
collapse. A colleague begins CPR
immediately. Describe how you would
direct the management of this patient.
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Case Scenario
Monitor Reads:
You’re on a flight to Hawaii
A flight attendant asks “Would a healthcare
provider please come to the middle galley?”
„ At middle galley: 2 flight attendants are doing
chest compressions and pocket-mask
ventilations on a 55-year-old man
„ Lying to one side: an opened,
partially deployed AED
„ What would you do next?
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Case #1:
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Which of the following are true?
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Defibrillation should be performed
immediately upon identifying Vfib/pulseless V-tach
The third shock in the initial tx of V-Fib
should be 360J
The algoithm for pulseless V-tach is the
same as that for V-fib
All the above
Case #2:
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True or False?
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If medications are delayed when treating
V-fib it is ok to repeat your stacked shocks.
Case #3:
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If a patient develops V-fib during
synchronized electrical cardioversion:
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Immediately give Lidocaine IV
Attempt to resynchronize and convert back
to the tachyrhythm
Switch off synchronization mode and
defibrillate at 200J
Perform a precordial thump
Immediately start chest compressions
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