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 „ „

End-tidal CO2 and/or Esophageal detector devices

B = Breathing: prevent airway device dislodgment: „ „

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 100

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

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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 „ „

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 „

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 „ „ „ „ „

Check responsiveness Airway Breathing Circulations Confirm in 2 or more leads „ „ „

MNEMONICS: ASYSTOLE „

TEA „ „ „

Transcutaneous pacing Epinephrine Atropine

Transcutaneous pacing EpinephrineAtropine

MNEMONICS: PEA PEA Problem Epi Atropine

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(5H and 5T) „ „ „ „ „ „ „ „ „ „

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 – – –

3.

Wide-complex tachycardia of unknown type – –

4.

Paroxysmal supraventricular tachycardia (PSVT) Junctional tachycardia Multifocal atrial or ectopic atrial tachycardia Wide-complex tachycardia—not specified Aberrant conduction of an SVT

Ventricular tachycardia – – –

Stable monomorphic VT Stable polymorphic VT (baseline QT interval normal) Stable polymorphic VT (baseline QT interval prolonged = torsades de pointes

MNEMONICS: Synchronized Cardioversion: „

Oh Say It Isn’t So „ „ „ „ „

O2 saturation monitor Suction equipment IV line Intubation equipment Sedation and analgesics

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4. Stable Monomorphic/ Polymorphic VT „

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 „ „

Ventricular or Supraventricular with aberrant conduction?

Normal: treat ischemia, correct electrolytes (amiodarone or lidocaine if heart impaired) Prolonged: correct electrolytes „

Magnesium, overdrive pacing, isoproterenol, dilantin, lidocaine

Ventricular Tachycardia

Ventricular Fibrillation

MNEMONICS: Pulseless Vtach/Vfib: „ „ „ „ „ „ „ „

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)

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• 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

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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. „

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? „ „

Case #1: „

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: „

True or False? „

If medications are delayed when treating V-fib it is ok to repeat your stacked shocks.

Case #3: „

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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