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Shock to the Heart: A Pharmacist’s Role in the Code team Tyler Osgood PharmD Pharmacist St. Luke’s Boise Regional Medical Center 03/06/16 Disclosures The presenter for this continuing education activity has reported no relevant financial contributions Objectives • Describe the role of each member of the code team while focusing on the pharmacist’s role • Discuss ways to be prepared for various code situations • Distinguish basic cardiac rhythms and the ACLS algorithms associated with the ACLS algorithm associated with them • Describe the differences between the 2010 and 2015 AHA ACLS guidelines Code Team Roles 1) Respiratory Therapy 2) Respiratory Therapy 3) Medication Nurse 4) Pharmacist 5) Team Leader 6) Compressions 7) Backup Compressions 8) Recorder 9) Administrative Support 10)Ancillary Support http://www.medscape.org/viewarticle/481221 11)Primary Care Nurse Pharmacists Role Assist with distribution of medications and supplies available on the crash cart Obtain additional medications from pharmacy as needed Prepare and label medications for administration as needed Provide drug information as it relates to drug compatibilities, administration, allergies, etc Pertinent Algorithms Robert W. Neumar et al. Part 1: Executive Summary: 2015 American Heart Association Guidelines Update Cardiopulmonary Resuscitation Field JM, Hazinski MF et al. 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation H's & T's Field JM, Hazinski MF et al. 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation Cardiac Arrest Robert W. Neumar et al. Part 1: Executive Summary: 2015 American Heart Association Guidelines Update Cardiopulmonary Resuscitation First Decision Point Robert W. Neumar et al. Part 1: Executive Summary: 2015 American Heart Association Guidelines Update Cardiopulmonary Resuscitation Rhythm Test 1 2 3 4 Robert W. Neumar et al. Part 1: Executive Summary: 2015 American Heart Association Guidelines Update Cardiopulmonary Resuscitation Intravenous Peripheral IV is preferred unless central line is already available Directions: Give by bolus injection unless otherwise specified Flush with 20mL bolus of IV fluid Elevate extremity for 10 – 20 seconds Field JM, Hazinski MF et al. 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation Intraosseous Can be established in all age groups Usually takes 30 – 60 seconds Preferred over endotracheal route Any ACLS drug or fluid given IV may be given IO Field JM, Hazinski MF et al. 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation Endotracheal • Narcan • Atropine • Vasopressin • Epinephrine • Lidocaine Optimal dose of most drugs unknown Typically 2 – 2.5 times the IV route Dilute dose in 5 – 10 ml of sterile water or NS Inject directly into ET tube Should we be flushing? Field JM, Hazinski MF et al. 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation Robert W. Neumar et al. Part 1: Executive Summary: 2015 American Heart Association Guidelines Update Cardiopulmonary Resuscitation Epinephrine • Dose: 1 mg IV/IO q 3 – 5 minutes during cardiac arrest • 2 – 2.5 mg endotracheal dose • Pearls: • Prepare dose prior to it being called • Remember flush with 20 ml IV fluid and elevate limb for 10 – 20 seconds • Available in 1:10,000 and 1:1,000 concentrations • Used in both VF, pVT, Asystole, and PEA Field JM, Hazinski MF et al. 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation Amiodarone • Consider for treatment of VF or pVT unresponsive to defibrillation, CPR, and vasopressor therapy • Dosing: • 1st Dose: 300 mg IV/IO push • 2nd Dose: 150 mg IV/IO push • Pearls: • • • • Amiodarone kit No utility in asystole, or PEA May be given as bolus May be given independent of timing of last dose of epinephrine Field JM, Hazinski MF et al. 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation Vasopressin? • No longer included in 2015 guidelines • Old Dose: 40 units IV/IO push to replace either 1st or 2nd dose of epinephrine • Pearls: • Medication should only be given once during cardiac arrest per old algorithms • Medication was removed from the guidelines for simplicity while not showing any superiority to epinephrine Robert W. Neumar et al. Part 1: Executive Summary: 2015 American Heart Association Guidelines Update Cardiopulmonary Resuscitation Special Circumstances • • • • • • • Asthma Anaphylaxis Pregnancy Morbidly obese Pulmonary embolism Electrolyte disturbances Drowning • • • • • • • Trauma Toxicity Hypothermia Avalanche victims During PCI After cardiac surgery Cardiac tamponade Eric J. Lavonas et al Pregnancy • Key Points: • Epinephrine is preferable to vasopressin in light of MOA • Routine sodium bicarb is still a • H’s and T’s (BEAU-CHOPS) bad idea (even worse here) • Bleeding • If the fundus is above the • Embolic causes umbilicus left uterine • Anesthetic complications displacement may relieve • Uterine atony aortocaval compression • Cardiac disease • Hand placement for compressions in same position • Hypertension • Other: think standard H’s and T’s • Energy requirements for defibrillation and drug doses are • Placenta abruptio/previa the same as a normal adult • Sepsis • Cesarean delivery indicated if ROSC not achieved within 4 minutes Carolyn M Zelop et al. Cardiopulmonary Arrest in Pregnancy. Methamphetamine Overdose • Keys to Success: • Fluid resuscitation with large volumes of NS • Correction of metabolic acidosis with sodium bicarbonate • Do we have any concerns with epinephrine use under this circumstance? https://adapaproject.org/bbk_temp/tikiindex.php?page=Leaf%3A+How+ do+nerves+communicate+with+each+other%3F Edward W. Boyer et al. Methamphetamine intoxication Pulmonary Embolism • Patient is admitted to the ICU with the diagnosis of pulmonary embolism. • Patient is hypotensive on norepinephrine and severely hypoxic • Echocardiogram shows right ventricular strain • The plan is to administer thrombolytics, however during intubation the patient loses a pulse. • What are your thoughts on thrombolytic therapy? Absolute contraindications Prior intracranial hemorrhage Known structural cerebral vascular lesion Known malignant intracranial neoplasm Ischemic stroke within three months (excluding stroke within three hours*) Suspected aortic dissection Active bleeding or bleeding diathesis (excluding menses) Relative contraindications History of chronic, severe, poorly controlled hypertension Severe uncontrolled hypertension on presentation (SBP >180 mmHg or DBP >110 mmHg) History of ischemic stroke more than three months prior Traumatic or prolonged (>10 minute) CPR or major surgery less than three weeks Recent (within two to four weeks) internal bleeding Noncompressible vascular punctures Recent invasive procedure For streptokinase/anistreplase - Prior exposure (more than five days ago) or prior allergic reaction to these agents Pregnancy Active peptic ulcer Pericarditis or pericardial fluid Current use of anticoagulant (eg, warfarin sodium) that has produced an elevated international normalized ratio (INR) >1.7 or prothrombin time (PT) >15 seconds Age >75 years Diabetic retinopathy Victor F Tapson, MD. Fibrinolytic therapy in acute pulmonary embolism and lower extremity deep vein thrombosis Most Common Regimens Alteplase Dose Reference 100 mg over 2 hours FDA labeling 0.6mg/kg ideal body weight over 2 minutes Levine M., et al Chest. 1990 Dec; 98 (6) 1473 – 9 0.6mg/kg (max 50 mg) over 15 minutes 1.) Goldhaber SZ et al. Chest 1994 Sep; 106 (3) 718-24, 2.) Sors H, et al. Chest. 1994 sep; 106 (3) 712-7 50 mg bolus x 2 (30 min apart) Ruiz-Bailen M, et al. Resuscitation 2001 Oct;51(1): 97-101 15 mg bolus followed by 85 mg infusion over 90 minutes Kurkciyan I, et al. Arch Intern Med. 2000 May 22; 160 (10): 1529-35 100 mg over 15 minutes Cavallaro F, et al. Acta anaesthesiol Scand. 2009 Mar; 53(3):400-2 Adapted from Top of Your License’ Code Response Alexander H. Flannery Pharm.D. BCPS Key Updates to Guidelines • Vasopressin was removed from the Cardiac Arrest algorithm for simplicity in light of no superiority to epinephrine • Compression rate updated to 100 – 120/min during BLS/ACLS • For those with unshockable rhythm, it may be reasonable to administer epinephrine as soon as feasible • Utilization of steroids in cardiac arrest is controversial however intra-arrest vasopressin, epinephrine, and methylprednisolone and post arrest hydrocortisone may be considered • Cardiac arrest in pregnancy: if the fundus is at or above the level of the umbilicus left uterine displacement may relieve aortocaval compression Robert W. Neumar et al. Part 1: Executive Summary: 2015 American Heart Association Guidelines Update Cardiopulmonary Resuscitation New Wild Things in the Literature Vasopressin, Steroids, Epinephrine Mentzelopoulos SD et al. Vasopressin, steroids, and epinephrine and neurologically favorablesurvival after in-hospital cardiac arrest: a randomized clinical trial. Vasopressin, Steroids, Epinephrine VSE Control OR (95% CI) P value All patients ROSC of > 20 min 83.9% 65.9% 2.98 (1.39 – 6.40) 0.005 Survival to discharge with CPC 1 or 2 13.9% 5.1% 3.28 (1.17 – 9.20) 0.020 3.74 (1.20 – 11.62) 0.020 Patients with post-resuscitation shock Survival to discharge with CPC 1 or 2 21.1% 8.2% Mentzelopoulos SD et al. Vasopressin, steroids, and epinephrine and neurologically favorable survival after in-hospital cardiac arrest: a randomized clinical trial. PARAMEDIC2 Trial RCT in UK (Universities of Warwick and Surrey) Epinephrine vs. Placebo Planned enrollment: 8,000 Primary outcome: 30 day survival What really is the role of drugs? http://www2.warwick.ac.uk/fac/med/resear ch/hscience/ctu/trials/critical/paramedic2/ Field JM, Hazinski MF et al. 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation Atropine • Indications: • First drug for symptomatic sinus bradycardia • May be beneficial in presence of some AV nodal block • Likely will not help with PEA or asystole • Will not work for Mobitz Type II second degree heart block • Dosing: • 0.5 mg IV q 3 – 5 min as needed • Max total dose: 3 mg or 0.04 mg/kg Field JM, Hazinski MF et al. 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation Transcutaneous Pacing • Indications: • • • • • Hemodynamically unstable bradycardia Symptomatic sinus bradycardia Mobitz type II second degree AV block Third degree heart block New left, right, or alternating BB or bifascicular block • Pearls: • Contraindicated in severe hypothermia and asystole • Do not assess carotid pulse to confirm mechanical capture • Analgesia and sedation for patient comfort Field JM, Hazinski MF et al. 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation Dopamine • Indications: • Second-line drug for symptomatic bradycardia • Hypotension with signs of shock • Precautions • Correct hypovolemia before initiating • Use with caution in cardiogenic shock with CHF • May cause tachyarrythmias/excessive vasoconstriction • Do not mix with sodium bicarbonate • Dosing: 2- 10 mcg/kg/min titrated to response Field JM, Hazinski MF et al. 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation Epinephrine • Indications: – Second-line drug for symptomatic bradycardia – Hypotension with signs of shock • Precautions – Increased myocardial O2 demand – High doses may be necessary in some poisonings • Dosing: 2- 10 mcg/min titrated to response Field JM, Hazinski MF et al. 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation Field JM, Hazinski MF et al. 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation Rhythm Test 1 2 3 Field JM, Hazinski MF et al. 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation Rhythm Test 1 2 3 Field JM, Hazinski MF et al. 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation Unstable Tachyarrythmias • 2 keys to management • Rapid recognition that the patient is symptomatic or unstable • Rapid recognition that the symptoms are caused by tachycardia • Drugs: Not typically indicated. Immediate cardioversion recommended. Field JM, Hazinski MF et al. 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation Narrow QRS Tachyarrythmia Pearls • Vagal maneuvers • Will terminate 25% of SVTs • Adenosine • May cause bronchospasm • Will terminate ~90% of reentry arrhythmias • Will not terminate Afib or Aflutter Field JM, Hazinski MF et al. 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation Adenosine • Initial Bolus: 6 mg given rapidly over 1 – 3 seconds followed by NS bolus of 20 ml then elevate the extremity • Optional 3 mg starting dose: • Patients on dipyridamole or carbamazepine • Heart transplant patients • Patients receiving through a central line • Second bolus: 12 mg can be given after 1 – 2 minutes if needed • Injection technique: • Watch rhythm strip during administration • Draw dose and flush in 2 separate syringes • Push as fast as possible followed by flush Precautions: In irregular, polymorphic wide-complex tachyarrhythmias, adenosine is contraindicated and may cause deterioration. Transient periods of sinus bradycardia or ventricular ectopy are common Field JM, Hazinski MF et al. 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation Wide QRS Tachyarrhythmia Pearls • A wide-complex tachycardia may represent either VT or a supraventricular rhythm with abnormal conduction • Remember think hemodynamic stability • Determine if rhythm is regular or irregular • Avoid AV nodal blocking agents in patients with preexitation • Adenosine, CCBs, Digoxin, B-blockers • Some experts proceed straight to electrical cardioversion others begin with antiarrhythmic agents • Amiodarone • Procainamide: Avoid if prolonged QTC or CHF • Sotalol: Avoid if prolonged QTC Leonard I Ganz et al. Approach to the management of wide QRS complex tachycardias. Pertinent Algorithms Field JM, Hazinski MF et al. 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care What Can We Do? • Announce yourself and your role • Speak up and push for meaningful interventions • Expand your comfortability • Infusion pumps • Medical equipment • Rhythm interpretation • Know your crash cart • Both Medication and Medical Equipment • Think of your H's and T's • Think ahead and prepare medications prior to being called when appropriate Questions • • • • • • • • • • • • • • Asthma Anaphylaxis Pregnancy Morbidly obese Pulmonary embolism Electrolyte disturbances Trauma Toxicity Hypothermia Drowning Electric shock Avalanche victims During PCI After Cardiac Surgery References Robert W. Neumar et al. Part 1: Executive Summary: 2015 American Heart Association Guidelines Update Cardiopulmonary Resuscitation and Emergency Cardiovascular care. Circulation. Field JM, Hazinski MF et al. 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2005; Mentzelopoulos SD et al. Vasopressin, steroids, and epinephrine and neurologically favorable survival after in-hospital cardiac arrest: a randomized clinical trial. JAMA. 2013 Alexander H. Flannery. Top of Your License' Code Response: Elevating the Pharmacist Role 2015 Midyear Clinical Meeting & Exhibition. Carolyn M Zelop et al. Cardiopulmonary Arrest in Pregnancy. UpToDate. Retrieved January 2016. http://www.uptodate.com/home http://www2.warwick.ac.uk/fac/med/research/hscience/ctu/trials/critical/paramedic2/ Terry L. Vanden Hoek et al. Part 12: Cardiac Arrest in Special Situations: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010 Eric J. Lavonas et al. Part 10: Special Circumstances of Resuscitation: 2015 American Heart Association Guidelines Update Cardiopulmonary Resuscitation and Emergency Cardiovascular care. Circulation. References Edward W. Boyer et al. Methamphetamine intoxication UpToDate. Retrieved January 2016. http://www.uptodate.com/home Leonard I Ganz et al. Approach to the management of wide QRS complex tachycardias. UpToDate. Retrieved January 2016 http://www.uptodate.com/home Alexander H. Flannery et al. Top of Your License Code Response: Elevating the Pharmacists Role. ASHP Midyear Clinical Meeting. December 7, 2015 Victor F Tapson, MD. Fibrinolytic therapy in acute pulmonary embolism and lower extremity deep vein thrombosis. UpToDate. Retrieved January 2016 http://www.uptodate.com/home
