Pulseless arrest: Difference between revisions
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{{Adult top}} [[pulseless arrest (peds)]].'' | |||
==Immediate== | ==Immediate== | ||
[[File:ACLS-arrest.png|thumb|Algorithm for cardiac arrest (Adapted from ACLS 2010)]] | |||
#Start [[CPR]] | #Start [[CPR]] | ||
#Give oxygen | #Give oxygen | ||
#Attach monitor/ | #Attach monitor/[[Defibrillation|defibrillator]] | ||
#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 | ||
Line 11: | Line 13: | ||
*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 | **1st line: [[Amiodarone]] 300mg IVP with repeat dose of 150mg as indicated | ||
**2nd line: [[Lidocaine]] 1-1. | **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 | ||
Line 22: | Line 24: | ||
#Severe Hypovolemia | #Severe Hypovolemia | ||
#Obstruction | #Obstruction | ||
#*[[Tension | #*[[Tension pneumothorax]] | ||
#*[[Cardiac | #*[[Pericardial effusion and tamponade|Cardiac tamponade]] | ||
#*Massive [[Pulmonary | #*Massive [[Pulmonary embolism]] | ||
#Pump Failure | #Pump Failure | ||
===[[ACLS (Treatable Conditions)|Treatable ACLS Conditions]] (H's and T's)=== | ===[[ACLS (Treatable Conditions)|Treatable ACLS Conditions]] (H's and T's)=== | ||
*Hypovolemia | *Hypovolemia | ||
*[[ | *[[Hypoxemia]] | ||
*Hydrogen ion (i.e. acidemia) | *Hydrogen ion (i.e. acidemia) | ||
*[[Hypokalemia|Hypo]]/[[hyperkalemia]] | *[[Hypokalemia|Hypo]]/[[hyperkalemia]] | ||
*[[Hypothermia]] | *[[Hypothermia]] | ||
*[[Tension Pneumothorax]] | *[[Tension Pneumothorax]] | ||
*[[Cardiac | *[[Pericardial effusion and tamponade|Cardiac tamponade]] | ||
*[[Toxicology ( | *[[Toxicology (main)|Toxins]] | ||
*[[ | *[[Pulmonary embolism|Thrombosis, pulmonary]] | ||
*[[ | *[[Acute coronary syndrome (main)|Thrombosis, coronary]] | ||
===PEA Evaluation by QRS=== | ===PEA Evaluation by QRS=== | ||
Line 56: | Line 58: | ||
==General== | ==General== | ||
*A (adjunct) - Place oropharyngeal airway | *'''A''' (adjunct) - Place oropharyngeal airway | ||
*B (breathing) - place on [[Ventilator]] to assure slow ventilation rate (attach to BVM mask) | *'''B''' (breathing) - place on [[Ventilator]] to assure slow ventilation rate (attach to BVM mask) | ||
**10-12 bpm, 500cc tidal volume, Fio2 100% | **10-12 bpm, 500cc tidal volume, Fio2 100% | ||
*C (compressions) - Switch out providers q pulse check; use metronome | *'''C''' (compressions) - Switch out providers q pulse check; use metronome | ||
*D - defibrillation | **100-120 compressions/min | ||
** | **Compress to a depth between 2-2.4 inches (5-6 cm) | ||
**Allow full recoil between compressions | |||
*A (advanced airway) | *'''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) | **Use [[LMA]] (NOT ET tube - no break in compressions required) | ||
*B (advanced breathing) | *'''B''' (advanced breathing) | ||
**Connect [[LMA]] to [[Ventilator]] | **Connect [[LMA]] to [[Ventilator]] | ||
***Pressure control 20, RR 10, insp rate 1.5-2s | ***Pressure control 20, RR 10, insp rate 1.5-2s | ||
*C (advanced circulation) | *'''C''' (advanced circulation) | ||
**Place [[IO]] instead of central line | **Place [[IO]] instead of central line | ||
*D (differential) | *'''D''' (differential) | ||
**[[Ultrasound: In Shock and Hypotension]] | **[[Ultrasound: In Shock and Hypotension]] | ||
==Refractory Ventricular Fibrillation== | ==Refractory Ventricular Fibrillation== | ||
''A patient is considered refractory after ≥3 defib, ≥3mg [[epinephrine | ''A patient is considered refractory after ≥3 defib, ≥3mg [[epinephrine]], and 300mg [[amiodarone]]'' | ||
=== | |||
#Place a second set of defib pads in an alternative location on the chest | ''The following therapies are largely based on case studies or case series'' | ||
===[[Double simultaneous external defibrillation | Dual Sequential Defibrillation]]<ref>Hoch DH et al. Double Sequential External Shocks for Refractory Ventricular fibrillation. JACC 1994; 23: 1141 – 5.</ref> <ref>Bero M et al. Changing the management of refractory ventricular fibrillation: the consideration of earlier utilization of dual sequential defibrillation. Am J Emerg Med. 2019 May 29. pii: S0735-6757(19)30359-6. doi: 10.1016</ref> === | |||
#Continue high quality CPR. Consider using devices such as LUCAS CPR to avoid ineffective CPR due to rescuer fatigue | |||
#Place a second set of defib pads in an alternative location on the chest (anterior/posterior and right upper chest/left lateral) | |||
#Deliver 200J (or 360J if monophasic) simultaneously from both defibrillators | |||
#Continue CPR | #Continue CPR | ||
===Esmolol for Electrical Storm <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><ref> Boehm KM. First report of survival in refractory ventricular fibrillation after dual-axis defibrillation and esmolol administration. West J Emerg Med. 2016 Nov;17(6):762-765. </ref><ref> Lee YH. Refractory ventricular fibrillation treated with esmolol. Resuscitation. 2016 Oct;107:150-5. doi: 10.1016. </ref>=== | |||
# | |||
#Deliver 360J simultaneously from both defibrillators | #Administer [[Esmolol]] bolus 500 mcg/kg IVP over 30 seconds (typical dose ranges 35-50 mg) | ||
#If ROSC, initiate 50 mcg/kg/min infusion <ref> Al-Khatib SM. 2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac arrest. Circulation. 2018 Sep 25;138(13):e272-e391. doi: 10.1161 </ref> | |||
#Deliver 200J (or 360J if monophasic) simultaneously from both defibrillators | |||
#Continue CPR | #Continue CPR | ||
Consider holding further epinephrine ([http://blog.wikem.org/the-current-state-of-refractory-vf/ The Current State of Refractory VF]) | |||
===[[Stellate Ganglion Nerve Block]] <ref>Margus, C, Correa, A, Cheung, W, et al. Stellate ganglion nerve block by point-of-care ultrasonography for treatment of refractory infarction-induced ventricular fibrillation. Ann Emerg Med. 2020;75(2):257–260. </ref>=== | |||
[[File:stellate ganglion block.png|thumb|The red star above denotes the intended target for lidocaine injection<ref>Margus, C, Correa, A, Cheung, W, et al. Stellate ganglion nerve block by point-of-care ultrasonography for treatment of refractory infarction-induced ventricular fibrillation. Ann Emerg Med. 2020;75(2):257–260.</ref>]] | |||
#Place probe over left anterior neck | |||
#Identify thyroid gland, carotid artery, C6/C7, longus colli muscle, and prevertebral fascia | |||
#Advance needle to stellate ganglion which is deep to prevertebral fascia and superficial to longus colli muscle | |||
#Inject 1-2 ml of 1% lidocaine without epinephrine and observe dissection of the muscle and fascia layers to confirm placement | |||
#With placement confirmed, inject the rest of the anesthetic for a total of 10ml of volume | |||
==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<ref>Böttiger BW et al. Lancet 2001;357:1583-5.</ref> | |||
**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<ref>Kearon C et al. Chest 2012; 141 (2)(suppl):e419s-e494s. | |||
Vanden Hoek TL et al. Circulation 2010; 122 (suppl):S829-S861.</ref> | |||
**Class IIc and Class IIa, respectively | |||
**2 hr infusion time recommended over long, 24hr (CHEST Class IIc) | |||
==See Also== | ==See Also== | ||
*[[ACLS (Main)]] | *[[ACLS (Main)]] | ||
*[[Brain | *[[Double simultaneous external defibrillation]] | ||
*[[Post | *[[Brain death]] | ||
*[[Pediatric Pulseless | *[[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] | |||
==References== | ==References== | ||
<references/> | <references/> | ||
[[Category: | [[Category:Cardiology]] | ||
[[Category:Critical Care]] | [[Category:Critical Care]] | ||
[[Category:EMS]] | [[Category:EMS]] |
Revision as of 01:48, 22 January 2021
This page is for adult patients. For pediatric patients, see: pulseless arrest (peds).
Immediate
- Start CPR
- Give oxygen
- Attach monitor/defibrillator
- 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)
- Epi 1mg q3-5min
- Three major mechanisms of PEA (3 & 3 Rule)
- Severe Hypovolemia
- Obstruction
- Pump Failure
Treatable ACLS Conditions (H's and T's)
- Hypovolemia
- Hypoxemia
- Hydrogen ion (i.e. acidemia)
- Hypo/hyperkalemia
- Hypothermia
- Tension Pneumothorax
- Cardiac tamponade
- Toxins
- Thrombosis, pulmonary
- Thrombosis, coronary
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
- Cardiac tamponade
- Tension pneumothorax
- Mechanical hyperinflation
- Pulmonary embolism
- Acute MI with myocardial rupture
QRS Widened
Metabolic LV Problem – Ultrasound should show hypokinetic LV
- Severe hyperkalemia
- Sodium-channel blocker toxicity (Ex. Tricyclic (TCA) toxicity)
- Agonal rhythm
- Acute MI with pump failure
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
- 100-120 compressions/min
- Compress to a depth between 2-2.4 inches (5-6 cm)
- Allow full recoil between compressions
- 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
- Connect LMA to Ventilator
- 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
The following therapies are largely based on case studies or case series
Dual Sequential Defibrillation[2] [3]
- Continue high quality CPR. Consider using devices such as LUCAS CPR to avoid ineffective CPR due to rescuer fatigue
- Place a second set of defib pads in an alternative location on the chest (anterior/posterior and right upper chest/left lateral)
- Deliver 200J (or 360J if monophasic) simultaneously from both defibrillators
- Continue CPR
Esmolol for Electrical Storm [4][5][6]
- Administer Esmolol bolus 500 mcg/kg IVP over 30 seconds (typical dose ranges 35-50 mg)
- If ROSC, initiate 50 mcg/kg/min infusion [7]
- Deliver 200J (or 360J if monophasic) simultaneously from both defibrillators
- Continue CPR
Consider holding further epinephrine (The Current State of Refractory VF)
Stellate Ganglion Nerve Block [8]
- Place probe over left anterior neck
- Identify thyroid gland, carotid artery, C6/C7, longus colli muscle, and prevertebral fascia
- Advance needle to stellate ganglion which is deep to prevertebral fascia and superficial to longus colli muscle
- Inject 1-2 ml of 1% lidocaine without epinephrine and observe dissection of the muscle and fascia layers to confirm placement
- With placement confirmed, inject the rest of the anesthetic for a total of 10ml of volume
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[10]
- 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[11]
- Class IIc and Class IIa, respectively
- 2 hr infusion time recommended over long, 24hr (CHEST Class IIc)
See Also
- ACLS (Main)
- Double simultaneous external defibrillation
- Brain death
- Post cardiac arrest
- Pediatric pulseless arrest
External Links
References
- ↑ 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.
- ↑ Hoch DH et al. Double Sequential External Shocks for Refractory Ventricular fibrillation. JACC 1994; 23: 1141 – 5.
- ↑ Bero M et al. Changing the management of refractory ventricular fibrillation: the consideration of earlier utilization of dual sequential defibrillation. Am J Emerg Med. 2019 May 29. pii: S0735-6757(19)30359-6. doi: 10.1016
- ↑ 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.
- ↑ Boehm KM. First report of survival in refractory ventricular fibrillation after dual-axis defibrillation and esmolol administration. West J Emerg Med. 2016 Nov;17(6):762-765.
- ↑ Lee YH. Refractory ventricular fibrillation treated with esmolol. Resuscitation. 2016 Oct;107:150-5. doi: 10.1016.
- ↑ Al-Khatib SM. 2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac arrest. Circulation. 2018 Sep 25;138(13):e272-e391. doi: 10.1161
- ↑ Margus, C, Correa, A, Cheung, W, et al. Stellate ganglion nerve block by point-of-care ultrasonography for treatment of refractory infarction-induced ventricular fibrillation. Ann Emerg Med. 2020;75(2):257–260.
- ↑ Margus, C, Correa, A, Cheung, W, et al. Stellate ganglion nerve block by point-of-care ultrasonography for treatment of refractory infarction-induced ventricular fibrillation. Ann Emerg Med. 2020;75(2):257–260.
- ↑ Böttiger BW et al. Lancet 2001;357:1583-5.
- ↑ Kearon C et al. Chest 2012; 141 (2)(suppl):e419s-e494s. Vanden Hoek TL et al. Circulation 2010; 122 (suppl):S829-S861.