Pulseless arrest: Difference between revisions
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==Immediate==
==Immediate==
#Start CPR
[[File:ACLS-arrest.png|thumb|Algorithm for cardiac arrest (Adapted from ACLS 2010)]]
#Start [[CPR]]
#Give oxygen
#Give oxygen
#Attach monitor/defibrilator
#Attach monitor/defibrilator
#Rhythm shockable?
#Rhythm shockable?


== V-Fib and Pulseless V-Tach (Shockable) ==
==V-Fib and Pulseless V-Tach (Shockable)==
*Shock as quickly as possible and resume CPR immediately after shocking
*Shock as quickly as possible and resume CPR immediately after shocking
**Biphasic - 200J
**Biphasic - 200J
**Monophasic - 360 J
**Monophasic - 360 J
*Give Epi 1mg if (shock + 2min of CPR) fails to convert the rhythm
*Give [[Epi]] 1mg if (shock + 2min of CPR) fails to convert the rhythm
*Give antiarrhythmic if (2nd shock + 2min of CPR) again fails
*Give [[antiarrhythmic]] if (2nd shock + 2min of CPR) again fails
**1st line: [[Amiodarone]] 300mg IVP w/ repeat dose of 150mg as indicated
**1st line: [[Amiodarone]] 300mg IVP with repeat dose of 150mg as indicated
**2nd line: [[Lidocaine]] 1-1.5 mg/kg then 0.5-0.75 mg/kg q5-10min
**2nd line: [[Lidocaine]] 1-1.5mg/kg then 0.5-0.75mg/kg q5-10min
**Polymorphic V-tach: [[Magnesium]] 2g IV, followed by maintenance infusion
**Polymorphic V-tach: [[Magnesium]] 2g IV, followed by maintenance infusion


== Asystole and PEA (Non-Shockable)==
==Asystole and PEA (Non-Shockable)==
[[File:PEA.png|thumbnail]]
[[File:PEA.png|thumbnail]]
*[[epinephrine|Epi]] 1mg q3-5min
*[[epinephrine|Epi]] 1mg q3-5min


*3 & 3 Rule:
*Three major mechanisms of PEA (3 & 3 Rule)
Three major mechanisms of PEA
#Severe Hypovolemia
#Severe Hypovolemia
#Obstruction
#Obstruction
##Tension Pneumothorax
#*[[Tension pneumothorax]]
##Cardiac Tamponade
#*[[Pericardial effusion and tamponade|Cardiac tamponade]]
##Massive Pulmonary Embolus
#*Massive [[Pulmonary embolism]]
#Pump Failure
#Pump Failure


===[[ACLS (Treatable Conditions)|Treatable ACLS Conditions]] (H's and T's)===
*Hypovolemia
*[[Hypoxemia]]
*Hydrogen ion (i.e. acidemia)
*[[Hypokalemia|Hypo]]/[[hyperkalemia]]
*[[Hypothermia]]
*[[Tension Pneumothorax]]
*[[Pericardial effusion and tamponade|Cardiac tamponade]]
*[[Toxicology (main)|Toxins]]
*[[Pulmonary embolism|Thrombosis, pulmonary]]
*[[Acute coronary syndrome (main)|Thrombosis, coronary]]


Consider H's and T's
===PEA Evaluation by QRS===
#Hypovolemia
Differential based on QRS being narrow or wide and aided by ultrasound
#Hypoxia
====QRS Narrow====
#Hydrogen ion
Mechanical RV Problem – Ultrasound should show hyperdynamic LV and potential cause
#Hypo/hyperkalemia
*[[Cardiac tamponade]]
#Hypothermia
*[[Tension pneumothorax]]
*[[Deterioration after intubation|Mechanical hyperinflation]]
*[[Pulmonary embolism]]
*[[ST-Elevation Myocardial Infarction (STEMI)|Acute MI with myocardial rupture]]
====QRS Widened====
Metabolic LV Problem – Ultrasound should show hypokinetic LV
*[[Hyperkalemia|Severe hyperkalemia]]
*Sodium-channel blocker toxicity (Ex. [[Tricyclic (TCA) toxicity]])
*Agonal rhythm
*[[ST-Elevation Myocardial Infarction (STEMI)|Acute MI with pump failure]]


#Tension pneumothorax
==General==
#Tamponade
*'''A''' (adjunct) - Place oropharyngeal airway
#Toxins
*'''B''' (breathing) - place on [[Ventilator]] to assure slow ventilation rate (attach to BVM mask)
#Thrombosis, pulmonary
**10-12 bpm, 500cc tidal volume, Fio2 100%
#Thrombosis, coronary
*'''C''' (compressions) - Switch out providers q pulse check; use metronome
*'''D''' - defibrillation
**May be ok to shock during compressions if wearing gloves and using biphasic device<ref>Lloyd MS, Heeke B, Walter PF, and Langberg JJ. Hands-on defibrillation: an analysis of current flow through rescuers in direct contact with patients during biphasic external defibrillation. Circulation. 2008; 117:2510-2514.</ref>
**Precharge prior to pulse & rhythm check to increase overall compression time
*'''A''' (advanced airway)
**Use [[LMA]] (NOT ET tube - no break in compressions required)
*'''B''' (advanced breathing)
**Connect [[LMA]] to [[Ventilator]]
***Pressure control 20, RR 10, insp rate 1.5-2s
*'''C''' (advanced circulation)
**Place [[IO]] instead of central line
*'''D''' (differential)
**[[Ultrasound: In Shock and Hypotension]]


==Refractory Ventricular Fibrillation==
''A patient is considered refractory after ≥3 defib,  ≥3mg [[epinephrine]], and 300mg [[amiodarone]]''
===[[Double simultaneous external defibrillation | DSED]]<ref>Hoch DH et al. Double Sequential External Shocks for Refractory Ventricular fibrillation. JACC 1994; 23: 1141 – 5.</ref> & Esmolol for Failure of Standard ACLS<ref>Driver BE, Debaty G, Plummer DW, et al. Use of esmolol after failure of standard cardiopulmonary resuscitation to treat patients with ventricular fibrillation. Resuscitation. 2014; 85(10):1337-1341.</ref>===
#Place a second set of defib pads in an alternative location on the chest
#Continue CPR
#Deliver 200J (or 360J if monophasic) simultaneously from both defibrillators
#Continue CPR
#Give [[Esmolol]] bolus at 0.5mg/kg and start drip at 0.1mg/kg
#Deliver 200J (or 360J if monophasic) simultaneously from both defibrillators
#Continue CPR


See Also: [[ACLS (Treatable Conditions)]]
Consider holding further epinephrine ([http://blog.wikem.org/the-current-state-of-refractory-vf/ The Current State of Refractory VF])


==General==
==Fibrinolytics==
*A (adjunct) - Place oropharyngeal airway
===Dosing===
*B (breathing) - place on [[Ventilator]] to assure slow ventilation rate (attach to BVM mask)
*Alteplase 0.6mg/kg IV push x1 given over 15 min (± heparin 5000 unit bolus), and then repeated 30 min after if still no ROSC<ref>Böttiger BW et al. Lancet 2001;357:1583-5.</ref>
**10-12 bpm, 500cc tidal volume, Fio2 100%
**Heparin may be bolused with tPA or after ROSC obtained
*C (compressions) - Switch out providers q pulse check; use metronome
**Max doses of 50mg may be as efficacious as 100mg
*D - defibrillation
**Consider at least 20min of CPR after last dose of tPA before ending code
**Ok to shock during compressions if wearing gloves and using biphasic device


*A (advanced airway)
===Guidelines and Recommendations===
**Use LMA (NOT ET tube - no break in compressions required)
*ACLS 2010 does not yet recommend routine thrombolytics (Class III)
*B (advanced breathing)
*CHEST 2012 and ACLS 2010 recommends in acute [[PE]] or high suspicion<ref>Kearon C et al. Chest 2012; 141 (2)(suppl):e419s-e494s.
**Connect LMA to [[Ventilator]]
Vanden Hoek TL et al. Circulation 2010; 122 (suppl):S829-S861.</ref>
***Pressure control 20, RR 10, insp rate 1.5-2s
**Class IIc and Class IIa, respectively
*C (advanced circulation)
**2 hr infusion time recommended over long, 24hr (CHEST Class IIc)
**Place IO instead of central line
*D (differential)
**[[Ultrasound: In Shock and Hypotension]]


==See Also==
==See Also==
*[[ACLS (Main)]]
*[[ACLS (Main)]]
*[[Brain Death]]
*[[Double simultaneous external defibrillation]]
*[[Post Cardiac Arrest]]
*[[Brain death]]
*[[Pediatric Pulseless Arrest]]
*[[Post cardiac arrest]]
*[[Pediatric pulseless arrest]]
 
==External Links==
*[http://ddxof.com/simplified-acls-algorithms/ DDxOf: Simplified ACLS Algorithms]
*[http://www.blog.numose.com/emed-basics/pulseless Numose EMed: The Pulseless Patient]


==Source==
==References==
*Desbiens NA. Simplifying the diagnosis and management of pulseless electrical activity in adults: a qualitative review. Critical Care Medicine. 2008;36(2):391–396.
<references/>
*AHA 2010 ACLS Guidelines
*EMCrit Podcast #31


[[Category:Airway/Resus]]
[[Category:Cardiology]]
[[Category:Cards]]
[[Category:Critical Care]]
[[Category:EMS]]

Revision as of 23:44, 8 August 2018

Immediate

Algorithm for cardiac arrest (Adapted from ACLS 2010)
  1. Start CPR
  2. Give oxygen
  3. Attach monitor/defibrilator
  4. Rhythm shockable?

V-Fib and Pulseless V-Tach (Shockable)

  • Shock as quickly as possible and resume CPR immediately after shocking
    • Biphasic - 200J
    • Monophasic - 360 J
  • Give Epi 1mg if (shock + 2min of CPR) fails to convert the rhythm
  • Give antiarrhythmic if (2nd shock + 2min of CPR) again fails
    • 1st line: Amiodarone 300mg IVP with repeat dose of 150mg as indicated
    • 2nd line: Lidocaine 1-1.5mg/kg then 0.5-0.75mg/kg q5-10min
    • Polymorphic V-tach: Magnesium 2g IV, followed by maintenance infusion

Asystole and PEA (Non-Shockable)

PEA.png
  • Epi 1mg q3-5min
  • Three major mechanisms of PEA (3 & 3 Rule)
  1. Severe Hypovolemia
  2. Obstruction
  3. Pump Failure

Treatable ACLS Conditions (H's and T's)

PEA Evaluation by QRS

Differential based on QRS being narrow or wide and aided by ultrasound

QRS Narrow

Mechanical RV Problem – Ultrasound should show hyperdynamic LV and potential cause

QRS Widened

Metabolic LV Problem – Ultrasound should show hypokinetic LV

General

  • A (adjunct) - Place oropharyngeal airway
  • B (breathing) - place on Ventilator to assure slow ventilation rate (attach to BVM mask)
    • 10-12 bpm, 500cc tidal volume, Fio2 100%
  • C (compressions) - Switch out providers q pulse check; use metronome
  • D - defibrillation
    • May be ok to shock during compressions if wearing gloves and using biphasic device[1]
    • Precharge prior to pulse & rhythm check to increase overall compression time
  • A (advanced airway)
    • Use LMA (NOT ET tube - no break in compressions required)
  • B (advanced breathing)
    • Connect LMA to Ventilator
      • Pressure control 20, RR 10, insp rate 1.5-2s
  • C (advanced circulation)
    • Place IO instead of central line
  • D (differential)

Refractory Ventricular Fibrillation

A patient is considered refractory after ≥3 defib, ≥3mg epinephrine, and 300mg amiodarone

DSED[2] & Esmolol for Failure of Standard ACLS[3]

  1. Place a second set of defib pads in an alternative location on the chest
  2. Continue CPR
  3. Deliver 200J (or 360J if monophasic) simultaneously from both defibrillators
  4. Continue CPR
  5. Give Esmolol bolus at 0.5mg/kg and start drip at 0.1mg/kg
  6. Deliver 200J (or 360J if monophasic) simultaneously from both defibrillators
  7. Continue CPR

Consider holding further epinephrine (The Current State of Refractory VF)

Fibrinolytics

Dosing

  • Alteplase 0.6mg/kg IV push x1 given over 15 min (± heparin 5000 unit bolus), and then repeated 30 min after if still no ROSC[4]
    • Heparin may be bolused with tPA or after ROSC obtained
    • Max doses of 50mg may be as efficacious as 100mg
    • Consider at least 20min of CPR after last dose of tPA before ending code

Guidelines and Recommendations

  • ACLS 2010 does not yet recommend routine thrombolytics (Class III)
  • CHEST 2012 and ACLS 2010 recommends in acute PE or high suspicion[5]
    • Class IIc and Class IIa, respectively
    • 2 hr infusion time recommended over long, 24hr (CHEST Class IIc)

See Also

External Links

References

  1. ↑ Lloyd MS, Heeke B, Walter PF, and Langberg JJ. Hands-on defibrillation: an analysis of current flow through rescuers in direct contact with patients during biphasic external defibrillation. Circulation. 2008; 117:2510-2514.
  2. ↑ Hoch DH et al. Double Sequential External Shocks for Refractory Ventricular fibrillation. JACC 1994; 23: 1141 – 5.
  3. ↑ Driver BE, Debaty G, Plummer DW, et al. Use of esmolol after failure of standard cardiopulmonary resuscitation to treat patients with ventricular fibrillation. Resuscitation. 2014; 85(10):1337-1341.
  4. ↑ Böttiger BW et al. Lancet 2001;357:1583-5.
  5. ↑ Kearon C et al. Chest 2012; 141 (2)(suppl):e419s-e494s. Vanden Hoek TL et al. Circulation 2010; 122 (suppl):S829-S861.
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