MEGA CODE

Sense

React

Result !!

TODAY

Review the latest changes in BLS & ACLS

Review of most common & important EKG Rhythms.

ACLS pulseless algorithm

Responsiveness

Primary A,B,C,D

Primary A,B,C,D

2005 International Consensus Conference.Circulation 2005;112:III-17

Secondary A,B,C,D

Secondary A,B,C,D

3

121

2

3

Secondary A,B,C,D

1. Primary confirmation

1. Visualizes ETT goes through the vocal cords

2. Observes vapors in the tube

3. Chest rise

4. 5 point auscultation of the chest

Secondary A,B,C,D

Secondary A,B,C,D

Secondary A,B,C,D

Secondary A,B,C,D

– Circulation

1. Establish IV access

2. Identify rhythm monitor

3. Administer drugs

4. “appropriate for rhythm and condition”

Ewy, G. A. Circulation 2005;111:2134-2142

Simultaneous recording of aortic diastolic (red) and right atrial (yellow) pressures during CPR in

which 2 ventilations are delivered within 4-second time period

Secondary A,B,C,D

Secondary A,B,C,D

– Deferential Diagnosis

– search for and treat identified

reversible causes

Secondary A,B,C,D

6 H’s

– Hypovolemia

– Hypoxia

– Hydrogen Ions “acidemia”

– Hyperkalemia / Hypokalemia

– Hypothermia

– Hypoglycemia

6 T’s

– Tablets

– Thrombosis “coronary”

– Thrombosis “Pulmonary”

– Tension pneumothorax

– Tamponade, Cardiac

– Trauma

– Checking the heart rhythm

– Checking the pulse

– inserting airway devices

– administration of drugs should be done

Asystole

– “Flat line” protocol:

1. Check leads attachment.

2. Check leads selection

3. Power on/off

4. Check the gain

VF pulseless VT

EKG review

Three questions:

1. Rate

2. QRS narrow or wide

3. P wave & PR interval

1. Tachy vs. Brady

100 < rate < 60

1. Supraventricular vs. ventricular

2. Source of rhythm & blocks

Medications

1. Why? (Actions)

2. When? (Indications)

3. How? (Dose)

4. Watch Out! (Precautions)

What is the most important medication in the cardiac arrest?

O2

How to give the medicationduring CRP?

• I.V.– Fast I.V. Bolus.

– 10 cc N.S. flush.

– Raise the arm.

– Use central venous access if it available.

• E.T.T– 2-3 times the I.V. dose

– Diluted 10cc N.S.

– 3-4 ambo-bag “to

diffuse the medication”

Which Meds can be given

through E.T.T?

NAVEL

Naloxon Atropine Vasopressin Epinephrine Lidocaine

Which Meds can be given

through E.T.T?

Epinephrine

• Action : α & β – adrenergic agonist activity

• Indication: all Pulseless rhythms.

• Dose:• initial dose 1mg ( 10mL of 1:10 000 solution )

• Additional doses of 1mg every 3- 5 min

• No maximum dose.

• Precautions: • PVC with digitalis.

• Hypertension

• Myocardial ischemia

Vasopressin

• Survival higher in patients who had higher endogenous vasopressin 1,2

• Action :

• Vasoconstriction by direct stimulation of the smooth muscle V1 receptor.

• Combination with epinephrine resulted in decreased cerebral perfusion 3

• increase coronary perfusion and cerebral oxygen delivery during CPR 4

• Has no β – adrenergic activity.

• Indication: all Pulseless rhythms.

• Dose:

– Start with 40 units I.V. once.

– Don’t combine with epinephrine

Vasopressin & Epinephrine

no statistically significant differences between

vasopressin and epinephrinefor death within 24 hrs or death before hospital discharge after a

successful CPR.

• There is thus insufficient evidence to support or refute the use of vasopressin as an alternative to or in combination with epinephrine in any cardiac arrest rhythm.

Atropine

– Action : vagolytic action “SA and AV node”

– Indication: asystole & PEA with rhythm < 60/min .

– Dose:

– initial dose 1 mg

– Additional doses every 3-5 min

– max dose 3 mg/Kg

– Precautions:

– Myocardial ischemia

Amiodarone

– Action : Na+, K+, Ca++ channel blocker and α & β Blocker.

– Indication: shock refractory VF/ Pulseless VT.

– Dose:– initial dose 300 mg bolus

– Additional doses of 150 mg/kg

– Infusion dose of – 1 mg/min for 6 Hr ( 360 mg ) then

– 0.5 mg/min for 18 Hr ( 540 mg )

– Maximum dose of 2.2 Gram / 24 Hr

– Precautions: – Prolonged QT.

– Hypotension

– Negative Inotrope

Lidocaine

– Action : suppress ventricular arrhythmia, ectopy and prolong

the refractory period.

– Indication: shock refractory VF/ Pulseless VT.

– Dose:

– initial dose 1-1.5 mg/Kg

– Additional doses of 0.5 – 0.75 mg/kg

– max dose 3 mg/Kg

– Infusion dose of 1-4 mg/min

– Precautions:

– Decreased LVH.

Magnesium sulfate

• Indication: hypomagnesaemia & Torsades de pointes.

• Dose:

• initial dose 1-2 gram iv push over 2 min

• Infusion dose of 1 gram/hr

• Precautions:

• Hypotension.

• Renal failure.

Sodium bicarbonate

• Indications

– Pre-existing metabolic acidosis,

– ↑ K

– Prolonged arrest > 10 min

• Dose:

– 1 mEq / Kg

• Precautions:

– ↑ Na / Hyperosmolality

– Metabolic alkalosis

– Unfavorable shift of O2-Hb dissociation curve

• Contraindication

– hypoxic lactic acidosis

Medication 2005 changes

Epinephrine •No change

Vasopressin •All pulseless rhythms

•Can be used in E.T.T

Atropine •Maximum dose 3 mg

Amiodarone •No changes

Lidocaine •No changes

Medications

References

• Aung K, Htay T. Vasopressin for cardiac arrest: a systematic review and meta-analysis. Arch Intern Med 2005:17-24

• 2005 International Consensus Conference.Circulation 2005;112:III-29

• Linder KH, Strohmenger HU, Ensinger H, Hetzel WD, Ahnefeld FW, Georgieff M, Stress hormone response during and after cardiopulmonary resuscitation. Anesthesiology 1992;77:662-668

• Linder KH, Haak T, Keller A, Bothner U, Lurie KG, Release of endogenous vasopressors during and after cardiopulmonary resuscitation. Heart 1996;75:145-150

• Wenzel V, Linder KH, Augenstein S, Prengel AW, Strohmenger HU, Vasopressin combined with epinephrine decreases cerebral perfusion compared with vasopressin alone during cardiopulmonary resuscitation in pigs. Stroke. 1998;29:1462-1467: discussion 1467-1468.

• Babar SI, Berg RA, Hilwig RW, Kern KB, Ewy GA Vasopressin versus epinephrine during CPR: a randomized swine outcome study. Resuscitation 1999; 185-192

• Linder KH, Dricks B, Strohmenger HU, Prengel AW, Lindner IM, Lurie KG, Randomized comparison of epinephrine and vasopressin in patients with out of hospital VF. Lancet. 1997; 349: 535-537

References

• Kudenchuk PJet al. Amiodarone for resuscitation after out-of-hospital

cardiac arrest due to ventricular fibrillation. N Engl J Med. 1999:871-878

• Dorian P et al. Amiodarone as compared with lidocaine for shock-resistant

ventricular fibrillation. N Engl J Med 2002:884-90

• 2005 International Consensus Conference.Circulation 2005;112:III-17

• Paul Dorian, et al. NEJM 2002 Amiodarone as Compared with Lidocaine for

Shock-Resistant Ventricular Fibrillation

ACLS Pulseless Arrest Algorithm

Primary A,B,C,D

Primary A,B,C,D

Primary A,B,C,D

Primary A,B,C,D

Secondary A,B,C,D

Secondary A,B,C,D

Secondary A,B,C,D

Secondary A,B,C,D

Secondary A,B,C,D

Secondary A,B,C,D

• “Flat line” protocol:– Check leads attachment.

– Check leads selection

– Power on/off

– Check the gain