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CODE BLUE
MANAGEMENT
ACLS CASES
Part 4
Respiratory Arrest
Management of respiratory arrest
Giving supplementary oxygen
Opening the airway
Providing basic ventilation
Using adjuncts
suctioning
Respiratory Arrest
Critical concepts
Avoid delivering excessive ventilations
 Increases intra thoracic pressure
 Decreases venous return to the heart
↓Carbon dioxide
 Causes gastric inflation
 Vomiting
 aspiration
Respiratory Arrest
Administering supplementary O2
Acute cardiac symptoms
Respiratory distress
Titrate to maintain ≥94%
Respiratory Arrest
Basic airway opening techniques
Head tilt-chin lift
Jaw thrust
Respiratory Arrest
Airway management
OPA
NPA
Respiratory Arrest
Providing basic ventilation
Head tilt-chin lift
Jaw thrust
Mouth-to-mouth
Mouth-to-nose
Mouth-to-barrier
Bag-mask
Respiratory Arrest
Suctioning
Need suction force of -80 to -120 mmHg
Soft vs. rigid catheters
Catheter
Use for
Soft
•Aspiration of thin secretions
•Intra tracheal suctioning
•Suctioning when NPA is in use
Rigid
Orophraynx
Thick, particulate matter
Respiratory Arrest
Oropharyngeal suctioning
Step
1
Action
•Measure the catheter from tip of nose to earlobe
•Gently insert into oropharynx beyond tongue
2
•Apply suction (occlude) while withdrawing with a rotating
or twisting motion
•If using a rigid device (Yankauer) place tip gently into oral
cavity. Advance by pushing the tongue down to reach
oropharynx
Respiratory Arrest
Endotracheal tube suctioning
STEP
ACTION
1
•Sterile technique
2
•Insert catheter (Do not occlude)
3
•Apply suction (occlude) while withdrawing with a
rotating or twisting motion
•DO NOT exceed 10 seconds
•Precede and follow with 100% O2
Ventricular Fibrillation/Pulse less Ventricular
Tachycardia
Ventricular Fibrillation/Pulse less Ventricular
Tachycardia
What you will need
 Epinephrine
 Advanced airway
 Amiodarone
 Defibrillator
Managing Ventricular Fibrillation/Pulse less
Ventricular Tachycardia
VF/VT (left side)
Not recommend continued use of the AED when a
manual defibrillator is available
If you do not know the effective dose range,
deliver the maximal energy
Immediately after the shock, resume CPR
Cont…..
Safety during Defibrillation
Be sure oxygen is not flowing across patient’s
chest
When shocking, the operator should face the
patient, NOT the machine
Cont……
Paddles vs Pads
Reduces transthoracic impedance
Equally effective
Pads
reduce arcing
Allow for monitoring
Recommended by the AHA
Cont……
Rhythm Check
After 2 minutes (5 cycles)
Should not exceed 10 seconds
Perform a pulse-check—preferably during rhythm
analysis- only if an organized rhythm is present
ASYSTOLE
Give priority to Intravenous/Intraoseous
access
Search for underlying cause
Do not stop CPR to administer drugs
TCP not recommended
Routine shock not recommended
Asystole/PEA
Asystole/PEA
What you will need
 Epinephrine
 Defibrillator
PEA
Think of reversible causes (5 H & 5T’s)
5 H’s
Hypovolemia
Hypoxia
Hydrogen ion (acidosis) excess
Hypo/hyperkalemia
Hypothermia
Cont…..
5 T’s
Toxins
Tamponade, cardiac
Thrombosis, coronary
Thrombosis, pulmonary
Tension pneumothorax
Antiarrhytmics
Amiodarone
 First-line antiarrhythmic agent in cardiac arrest
 Improves rate of ROSC ( return of spontaneous
circulation)
Lidocaine
MgSO4 (Magnesium Sulphate)
1-2g (diluted in 10 mL D5W) bolus over 5 – 20 minutes
For Torsade
Cardiac Arrest Treatment Sequences
 Rhythm checks & shocks organized around 5 cycles (2
mins)
Physiologic Monitoring During CPR
AHA recommends using quantitative
waveform capnography in intubated patients
to monitor CPR quality
End-Tidal CO2
Main determinant of PETCO2 during CPR is blood
delivery to the lungs
PETCO2 <10 mm Hg during CPR suggest ROSC
unlikely. Improve chest compressions and
vasopressor therapy
If PETCO2 35-40, indicator of ROSC
Cont…..
Coronary Perfusion Pressure
Measured by intra-arterial catheter
<20 mm Hg, try to improve chest compressions
and vasopressor therapy
Monitoring CPR Quality
 Push hard (2 in) and fast ≥100/min
 Minimize interruptions
 Avoid excessive ventilation
 Rotate compressor every 2 minutes
 If no advanced airway, 30:2
 Quantitative waveform capnography
If PETCO2 <10 mmHg, attempt to improve CPR quality
 Intra-arterial pressure
If diastolic <20 mmHg, attempt to improve CPR quality
Routes of Access for Drugs
IV Route
Peripheral line preferred
Central line access not necessary
Drugs take 1-2 minutes to reach central circulation
Give by bolus
Follow with a 20mL bolus of IV fluid
Elevate extremity for about 10-20 secs
Routes of Access for Drugs
Intraosseous route
Preferred over the endotracheal route
Endotracheal Route
The optimal dose via this route is unknown
Typical dose is 2-2 ½ times the IV route
Dilute dose in 5 to 20 mL of H2O or saline
Intraosseous route
Adult Immediate Post-Cardiac Arrest Care
Post-Cardiac Arrest Care
Optimize ventilation and oxygenation
Waveform capnography
Use lowest FIO2 to maintain ≥94% (wean 100%)
Begin ventilations at 10-12 bpm, titrate to PaCO2
of 40-45 mm Hg
Avoid using ties that pass circumferentially around
neck  obstructs venous return from brain
Post-Cardiac Arrest Care
Foundational Facts: Recue breaths for CPR
with an advanced airway
During CPR, compression to ventilation ratio is
30:2
Once advanced airway is in place, compressions
no longer interrupted
Ventilating via advanced airway give 1 breath
every 6 to 8 secs. (8-10 bpm)
Post-Cardiac Arrest Care
Most common and easily reversible causes of
PEA
Hypovolemia
Hypoxia
Assess, assess, assess for their presence
Cardioversion
Synchronized vs. unsynchronized
Synchronized
Unstable SVT
Unstable atrial fibrillation
Unstable atrial flutter
Monomorphic tachycardia with pulses
Cardioversion
Energy doses for cardioversion
Initial: 200 J (monophasic)
120-200 J (Biphasic)
Atrial Flutter & SVT (50 to 100 J)