THE CODING PATIENT: ACLS REVIEW

PowerPoint PresentationEMERGENCY MEDICINE CLERKSHIP
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L O Y O L A U N I V E R S I T Y C H I C A G O • H E A L T H S C I E N C E S D I V I S I O N
TOPICS/GOALS
• The Basics: ABC’s • ACLS Medications • BLS/ACLS Algorithms • H’s & T’s Approach • Role of PoCUS • ROSC Care • Code Termination
Presenter
List of Topics Covered in this lecture
TOPICS NOT COVERED
• Rhythms with Pulses • Acute Coronary Syndromes • Acute Stroke Diagnosis and Management
Presenter
List of Topics NOT Covered in this lecture
CARDIAC ARREST
Presentation Notes
Who has seen a code run? One word to describe how it was run?
CARDIAC ARREST
• Name the only two evidence based interventions that impact patient survival to discharge after a cardiac arrest?
Early Defibrillation
Presentation Notes
Important to stress that there are only 2 evidenced based practices that lead to increased survival to hospital discharge: Early, quality CPR Early Defibrillation
THE BASICS: ABC’S
CIRCULATION: QUALITY CPR
Presentation Notes
RATE? ANSWER: 100-120 bpm 2010 ACLS Update stated 100 bpm minimum; the 2015 update added an upper limit maximum of 120 bpm Spotify playlist by New York Presbyterian hospital has an entire list of songs to choose from that meet these criteria (EVIDENCE: Class IIa, LOE C-LD) DEPTH ANSWER: 2.0-2.4” (5-6cm) 2015 ACLS Update: “During manual CPR…perform chest compressions to a depth of at least 2 inches or 5 cm for an average adult, while avoiding excessive chest compression depths (greater than 2.4 inches or 6 cm) (EVIDENCE: Class I, LOE C-LD). Don’t forget to allow recoil and heart to fill after compression EVIDENCE: 2015 recommendation: “It is reasonable for rescuers to avoid leaning on the chest between compressions to allow full chest wall recoil for adults in cardiac arrest” (EVIDENCE: Class IIa, LOE C-LD) RATIO ANSWER 30:2 (No advanced Airway) Continuous (Advanced Airway); approximately 1 breath every 6 seconds 2015 ACLS Update: “Consistent with the 2010 Guidelines, it is reasonable for rescuers to provide a compression-to-ventilation ratio of 30:2 for adults in cardiac arrest” (EVIDENCE Class IIa, LOE C-LD)
THE BASICS: ABC’S CIRCULATION: MINIMIZE INTERRUPTIONS
Presenter
Presentation Notes
It is important to minimize the number of interruptions when doing CPR Each interruption leads to a decrease in perfusion pressure 2015 ACLS Update: “In adult cardiac arrest, total preshock and postshock pauses in chest compressions should be as short as possible” EVIDENCE Class I, LOE C-LD) 2015 ACLS Update: “For adults in cardiac arrest receiving CPR without an advanced airway, it is reasonable to pause compressions for less than 10 seconds to deliver 2 breaths” (EVIDENCE: Class IIa, LOE C-LD)
THE BASICS: ABC’S CIRCULATION: TIPS TO MINIMIZE INTERRUPTIONS
• Continue CPR during airway attempts
• Rotate compressors after each cycle of CPR
• Using a timer during breaks
• Minimize Pre/Post defibrillation breaks
Presentation Notes
Continue CPR during airway attempts Person Intubating should continue attempt while CPR is ongoing if possible Rotate compressors after each cycle of CPR Decreases fatigue and chances one person will hold CPR Using a timer during breaks Have sombody count out loud the number of seconds the patient is not getting CPR if, for example, pads are being applied or a cardiac ultrasound is being performed Minimize Pre/Post defibrillation breaks Make sure CPR continues while the defibrillator is charging and restart immediately after shock
THE BASICS: ABC’S CPR: QUESTION OF EVIDENCE BASE FOR END-TIDAL CO2 IN LIEU OF PULSE CHECKS
• Use continuous CO2 capnography in lieu of pulse checks
• NEED TO DISCUSS THIS WITH BARBAS • Guideline chapter: “Part 7: Adult Advanced
Cardiovascular”3
Presentation Notes
Use continuous CO2 capnography in lieu of pulse checks NEED TO DISCUSS THIS WITH BARBAS Guideline chapter: “Part 7: Adult Advanced Cardiovascular”3 “Although no clinical study has examined whether titrating resuscitative efforts to physiologic parameters during CPR improves outcome, it may be reasonable to use physiologic parameters (quantitative waveform capnography, arterial relaxation diastolic pressure, arterial pressure monitoring, and central venous oxygen saturation) when feasible to monitor and optimize CPR quality, guide vasopressor therapy, and detect ROSC (Class IIb, LOE C-EO).”3 Management of Cardiac Arrest The 2015 International Liaison Committee on Resuscitation (ILCOR) systematic review considered one type of monitoring to be used during arrest, etCO2 measurement, for indicating an outcome related to cardiac arrest. During a cardiac arrest, etCO2 levels reflect the cardiac output generated by chest compressions. When a patient is found to have less than 10 mm Hg for an etCO2 value after 20 minutes of resuscitation, this has been associated with an extremely poor chance of ROSC and survival.1 NEED
THE BASICS: ABC’S CIRCULATION: DEFIBRILLATION
• Monophasic Defibrillators • 200J, 300J, 360J
• Biphasic Defibrillator • Manufacturer recommended Joules
• Loyola/Hines use Zoll Biphasic Defibrillator • 120J, 150J, 200J
Presenter
Presentation Notes
Different types of defibrillators; important to know which type your institution uses Types: Monophasic, Biphasic Loyola/Hines uses the Zoll Biphasic Defibrillator 2015 ACLS Update: “It is reasonable that selection of fixed versus escalating energy for subsequent shocks be based on the specific manufacturer’s instructions (EVIDENCE: Class IIa, LOE C-LD) 2015 ACLS Update: “If using a manual defibrillator capable of escalating energies, higher energy for second and subsequent shocks may be considered” (EVIDENCE: Class IIb, LOE C-LD)
THE BASICS: ABC’S AIRWAY/BREATHING
• Ratio? • 30:2 (No advanced Airway) • Continuous (Advanced Airway)
• Volume? • Enough • Approximately 500cc (average sized adult)
Presenter
Presentation Notes
RATIO? ANSWER 30:2 (No advanced Airway) Continuous (Advanced Airway) 2005 ACLS Update included recommendations for ratio of 15:2; this was changed to 30:2 in 2010 2015 Update: “Consistent with the 2010 Guidelines, it is reasonable for rescuers to provide a compression-to-ventilation ratio of 30:2 for adults in cardiac arrest” (EVIDENCE Class IIa, LOE C-LD) VOLUME? ANSWER: Enough to make the chest wall comfortably rise/fall Approximately 500cc (for an adult) Not the entire ambu bag Different sized ambu bags for pediatric patients
THE BASICS: ABC’S AIRWAY/BREATHING: QUALITY BAGGING TIPS
• Maintain a good seal • 2 handed/2 rescuer approach
• Jaw thrust/Chin Tilt Lift • Maintain control of C-spine
• Use airway adjuncts • Nasopharyngeal airway • Oropharyngeal airway
Presenter
Presentation Notes
Maintain a good seal It takes practice to develop skill to maintain 1-handed seal If not maintain good seal, consider 2 handed/2 rescuer approach Jaw thrust/Chin Tilt Lift Chin Tilt to open airway if you do not suspect cervical spine injury Jaw thrust maneuver if there is concern for cervical spine injury Other airway adjuncts Nasopharyngeal airway ACLS 2015 Update: “The presence of known or suspected basal skull fracture or severe coagulopathy, an oral airway is preferred.” (EVIDENCE Class IIA, LOE C) Oropharyngeal airway ACLS 2015 Update: “To facilitate delivery of ventilations with a bag-mask device, oropharyngeal airways can be used in unconscious (unresponsive) patients with no cough or gag reflex and should be inserted only by persons trained in their use.” (EVIDENCE: Class IIa, LOE C)
THE BASICS: ABC’S AIRWAY/BREATHING: ADVANCED AIRWAY
• If intubating, first-pass success decreases adverse events
• First-pass success • 14% Adverse Events
• Increased number of attempts increase the chance of adverse events
Presenter
Presentation Notes
Rate of adverse events: First attempt success = 14.2% AEs Two attempts = 47.2% AEs Three attempts = 63.6% AEs Four or more attempts = 70.6% AEs Adverse Events Defined as: Accidental Extubation, aspiration, cardiac arrest, cuff leak, dental trauma, dysrhthmia, esopghageal intubation, hypotension, laryngospasm, mainstem intubation, oxygen desaturation, pneumothorax REFERENCE: Sakles, John C, Stephen Chiu, Jarrod Mosier, Corrine Walker, and Uwe Stolz. (January 2013). The importance of first pass success when performing orotracheal intubation in the emergency department. Academic Emergency Medicine. 20(1), 71-78. doi 10.1111/acem.12055.
THE BASICS: ABC’S AIRWAY/BREATHING: CONFIRMING TUBE PLACEMENT
• Condensation in tube • Bilateral breath sounds • Lack of gastric sounds • Color capnography • End-tidal capnography
Presenter
Presentation Notes
There are multiple ways to confirm tube placement Condensation Bilateral breath sounds Lack of gastric sounds Color capnography In 2015, the AHA made a Level I recommendation that “Continuous waveform capnography is recommended in addition to clinical assessment as the most reliable method of confirming and monitoring correct placement of an ETT” EVIDENCE (Class I, LOE C-LD) A follow-up recommendation suggests that “If continuous waveform capnometry is not available, a nonwaveform CO2 detector, esophageal detector device, or ultrasound used by an experienced operator is a reasonable alternative.” (EVIDENCE Class IIa, LOE C-LD)
THE BASICS: ABC’S AIRWAY/BREATHING: ADVANCED AIRWAY
• Don’t let an airway supercede the initiation of CPR and/or defibrillation
• No evidence for improved outcomes by intubating versus bag-valve-mask use.
Presenter
Presentation Notes
ACLS 2010 Update: “During the first few minutes of witnessed cardiac arrest a lone rescuer should not interrupt chest compressions for ventilation. Advanced airway placement in cardiac arrest should not delay initial CPR and defibrillation for VF cardiac arrest.” (EVIDENCE Class I, LOE C) ACLS 2010 Update: “If advanced airway placement will interrupt chest compressions, providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC.” (EVIDENCE Class IIb, LOE C) ACLS 2015 Update: “Either a bag-mask device or an advanced airway may be used for oxygenation and ventilation during CPR in both the in-hospital and out-of-hospital setting” (EVIDENCE Class IIb, LOE C) ACLS 2015 Update: “For healthcare providers trained in their use, either an SGA device or an ETT may be used as the initial advanced airway during CPR.” (EVIDENCE Class IIb, LOE C-LD)
Presenter
Presentation Notes
This is Poncho, a Spanish police dog who was trained to recognize and treat cardiac arrest.
ACLS: MEDICATIONS
“While the [ACLS] drugs have theoretical benefits in selected situations, no medication has been shown to improve long term survival in humans after cardiac arrest. Priorities are defibrillation, oxygenation and ventilation together with external cardiac compression.”
AHA RECOMMENDATIONS
SOURCE: AHA ACLS 2015 Update Part 7: Adult Advanced Cardiovascular Life Support 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
• Name the only two evidence based interventions that impact patient survival to discharge after a cardiac arrest?
Early Defibrillation
Presentation Notes
Name the only two evidence based interventions that impact patient survival for discharge after cardiac arrest? Early defibrillation Early, quality CPR
ACLS: MEDICATIONS
• Frequency • Every 3-5 minutes
Presentation Notes
2015 ACLS Update “Standard-dose epinephrine (1 mg every 3 to 5 minutes) may be reasonable for patients in cardiac arrest” (EVIDENCE: Class IIb, LOE B-R) 2015 ACLS Update: “It may be reasonable to administer epinephrine as soon as feasible after the onset of cardiac arrest due to an initial non-shockable rhythm”. (EVIDENCE: Class IIb, LOE C-LD) 2015 ACLS Update: “High-dose epinephrine is not recommended for routine use in cardiac arrest” (EVIDENCE: Class III, LOE B-R) Epinephrine may help obtain ROSC and keep patients alive to admit, but there is no increased survival to discharge or survival to discharge with good neurologic outcomes as noted in the text of the ACLS AHA report: “One trial assessed short-term and longer-term outcomes when comparing standard-dose epinephrine to placebo. Standard-dose epinephrine was defined as 1 mg given IV/IO every 3 to 5 minutes. For both survival to discharge and survival to discharge with good neurologic outcome, there was no benefit with standard-dose epinephrine; however, the study was stopped early and was therefore underpowered for analysis of either of these outcomes (enrolled approximately 500 patients as opposed to the target of 5000).” “There was, nevertheless, improved survival to hospital admission and improved ROSC with the use of standard-dose epinephrine. Observational studies were performed that evaluated epinephrine, with conflicting results.”
ACLS: MEDICATIONS AMIODARONE
• Frequency • Can give 2 doses during code
• Dose • First dose: 300mg • Second dose: 150mg
Presenter
Presentation Notes
2018 ACLS Update: “Amiodarone or lidocaine may be considered for VF/pVT that is unresponsive to defibrillation. These drugs maybe particularly useful for patients with witnessed arrest, for whom time to drug administration may be shorter.” (EVIDENCE: Class IIb, LOE B-R)
ACLS: MEDICATIONS LIDOCAINE
• Frequency • Can give 2 doses during code
• Dose • First dose: 1 – 1.5 mg/kg • Second dose: 0.5 – 1.5 mg/kg
Presenter
Presentation Notes
For many years, amiodarone was the first-line drug to treat refractory pVT and v-fib though in the past lidocaine had been recommended. Based on most recent evidence, AHA recommended either Lidocaine or Amiodarone equally based on available evidence. There is no evidence to say that BOTH lidocaine and amiodarone shows any benefit though this has not been studied. “The 2015 ILCOR systematic review did not specifically address the selection or use of second-line antiarrhythmic medications in patients who are unresponsive to a maximum therapeutic dose of the first administered drug, and there are limited data available to direct such treatment.” 2018 ACLS Update: “Amiodarone or lidocaine may be considered for VF/pVT that is unresponsive to defibrillation. These drugs may be particularly useful for patients with witnessed arrest, for whom time to drug administration may be shorter” (EVIDENCE: Class IIb, LOE B-R) There were two main studies that went into this recommendation, one which favored lidocaine and another that favored amiodarone. “In…the ALIVE trial (Amiodarone Versus Lidocaine in Prehospital Ventricular Fibrillation Evaluation), 5 mg/kg amiodarone in polysorbate improved survival to hospital admission compared with 1.5 mg/kg lidocaine with polysorbate.” SOURCE: Dorian P, Cass D, Schwartz B, Cooper R, Gelaznikas R, Barr A. Amiodarone as compared with lidocaine for shock-resistant ventricular fibrillation.N Engl J Med. 2002; 346:884–890. doi: 10.1056/NEJMoa013029 “In ROC-ALPS (Resuscitation Outcomes Consortium–Amiodarone, Lidocaine or Placebo Study), a large out-of-hospital randomized controlled trial that compared captisol-based amiodarone with lidocaine or placebo for patients with VF/pVT refractory after at least 1 shock, there was no overall statistically significant difference in survival with good neurological outcome or survival to hospital discharge.” SOURCE: Kudenchuk PJ, Brown SP, Daya M, Rea T, Nichol G, Morrison LJ, Leroux B, Vaillancourt C, Wittwer L, Callaway CW, Christenson J, Egan D, Ornato JP, Weisfeldt ML, Stiell IG, Idris AH, Aufderheide TP, Dunford JV, Colella MR, Vilke GM, Brienza AM, Desvigne-Nickens P, Gray PC, Gray R, Seals N, Straight R, Dorian P; on behalf of the Resuscitation Outcomes Consortium Investigators. Amiodarone, lidocaine, or placebo in out-of-hospital cardiac arrest.N Engl J Med. 2016; 374:1711–1722. doi: 10.1056/NEJMoa1514204
ACLS: MEDICATIONS MAGNESIUM
Presenter
Presentation Notes
As of 2015, no longer sufficient evidence to support magnesium use. 2015 ACLS Guidelines: ”The routine use of magnesium for cardiac arrest is not recommended in adult patients” (EVIDENCE: Class III, LOE C-LD). 2010 ACLS Guidelines: “When VF/pulseless VT cardiac arrest is associated with torsades de pointes, providers may administer and IV/IO bolus of magnesium sulfate at a dose of 1 to 2 g diluted in 10 mL D5W (EVIDENCE: Class IIb, LOE C)
ACLS: MEDICATIONS
Presentation Notes
Atropine 2010 ACLS Guideliness “Available evidence suggests that routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit.” (EVIDENCE: Class IIb, LOE-B) Bicarbonate “Two studies demonstrated increased ROSC, hospital admission, and survival to hospital discharge associated with use of bicarbonate. However, the majority of studies showed no benefit or found a relationship with poor outcome….In some special resuscitation situations, such as preexisting metabolic acidosis, hyperkalemia, or tricyclic antidepressant overdose, bicarbonate can be beneficial” 2010 ACLS Guidelines “However, routine use of sodium bicarbonate is not recommended for patients in cardiac arrest.” (EVIDENCE Class III, LOE B) Calcium “Studies of calcium during cardiac arrest have found variable results on ROSC, and no trial has found a beneficial effect on survival either in or out of hospital.” 2010 ACLS Guidelines: “Routine administration of calcium for treatment of in-hospital and out-of-hospital cardiac arrest is not recommended (EVIDENCE: Class III, LOE B). Thrombolytics “Fibrinolytic therapy was proposed for use during cardiac arrest to treat both coronary thrombosis (acute coronary syndrome) with presumably complete occlusion of a proximal coronary artery and major life-threatening pulmonary embolism…2 large clinical trials failed to show any improvement in outcome with fibrinolytic therapy during CPR.” 2010 ACLS Guidelines: “Fibrinolytic therapy should not be routinely used in cardiac arrest (EVIDENCE Class III, LOE B). 2010 Cardiac Arrrest in Special Situations Update “When pulmonary embolism is presumed or known to be the cause of cardiac arrest, empirical fibrinolytic therapy can be considered” (EVIDENCE Class IIa, LOE B)
BLS: ALGORITHMS
Presentation Notes
This is the algorithm designed for lay people to recognize and start cardiac arrest. Amidst ABC tasks, remember to delegate/call for help. In the hospital this may include calling a code blue Out of hospital may include sending somebody to call 911
ACLS: ALGORITHMS
AHA ACLS Algorithm Major diagnostic fork: shockable rhythm or non-shockable rhythm Shockable rhythms: V-Fib, Pulseless V-Tach Non-shockable rhythms: Asystole, PEA
ACLS: ALGORITHMS
Presentation Notes
PEA/Asystole Algorithm 2015 ACLS Updates: “Vasopressin in combination with epinephrine offers no advantage as a substitute for standard-dose epinephrine in cardiac arrest.” (EVIDENCE: Class IIb, LOE B-R) 2015 ACLS Updates: “Vasopressin offers no advantage as a substitute for epinephrine in cardiac arrest.” (EVIDENCE: Class IIb, LOE B-R)
WIDE COMPLEX
Presenter
Presentation Notes
There have been attempts to organize/frame H/T’s into different conceptual categories Some have considered ”true” PEA a metabolic disease leading to wide complex rhythm PEA and “pseudo-PEA” as a mechanical problem leading to a narrow complex rhythm PEA (See Littman Reference) Regardless of the framework one memorizes these, according to AHA “PEA is often caused by reversible conditions and can be treated successfully if those conditions are identified and corrected. During each 2-minute period of CPR the provider should recall the H’s and T’s to identify factors that may have caused the arrest or may be complicating the resuscitative effort” Note Hypoglycemia/Trauma have been removed from most recent ACLS Updates 2010 causes of PEA SOURCES http://rebelem.com/a-new-pulseless-electrical-activity-algorithm/ Littmann et al. A Simplified And Structured Teaching Tool for the Evaluation and Management of Pulseless Electrical Activity. Med Princ Pract 2014; 23: 1 – 6. PMID: 23949188
POINT OF CARE ULTRASOUND
• “Ultrasound (cardiac or noncardiac) may be considered during the management of cardiac arrest, although its usefulness has not been well established”
AHA RECOMMENDATIONS
Presentation Notes
You may note physicians incorporating ultrasound more and more into cardiac arrest In the hands of a trained clinician it can be a helpful tool in identifying, correcting some of the causes of cardiac arrest. ACLS has some evidence based comments about the use of this technology 2015 ACLS UPDATES (EVIDENCE: Class IIb, LOE C-EO)
• “If a qualified sonographer is present and use of ultrasound does not interfere with the standard cardiac arrest treatment protocol, then ultrasound may be considered as an adjunct to standard patient evaluation”
AHA RECOMMENDATIONS
2015 ACLS UPDATES (EVIDENCE: Class IIb, LOE C-EO)
• Designed to minimize CPR interruption
CASA EXAM
Presentation Notes
If you are planning to use ultrasound as an adjunct to cardiac arrest, we want to provide a format for which to do so which may also be applicable to the undifferentiated hypotensive patient: The CASA Exam It is a systematic way to evaluate the heart for problem which would require intervention It is designed to minimize CPR downtime but the operator still needs to guard against it SOURCES: Clattenburg EJ et al. Implementation of the Cardiac arrest Sonographic Assessment (CASA) Protocol for Patients with Cardiac Arrest is Associated with Shorter CPR Pulse Checks. Resuscitation 2018. PMID: 30071262 https://rebelem.com/the-casa-exam-a-follow-up-study/
POINT OF CARE ULTRASOUND CASA EXAM
Presenter
Presentation Notes
Operator uses the first pulse check to check for cardiac tamponade Operator uses the second pulse check to check for right heart strain (signifying PE, or L heart failure) Operator uses the third pulse check to evaluate for cardiac activity as a marker for resuscitation potential Can use other breaks or continue to complete PTX/FAST ultrasound during the course of the code SOURCES: Clattenburg EJ et al. Implementation of the Cardiac arrest Sonographic Assessment (CASA) Protocol for Patients with Cardiac Arrest is Associated with Shorter CPR Pulse Checks. Resuscitation 2018. PMID: 30071262 https://rebelem.com/the-casa-exam-a-follow-up-study/
POINT OF CARE ULTRASOUND CONFIRMING TUBE PLACEMENT
Presenter
Presentation Notes
There is evidence to support the use of ultrasound in the confirmation of successful ETT placement Identify important landmarks on the photo including: Trachea: hyperechoic structure with shadowing behind Thyroid: Anterior and bilateral to the trachea Esophagus: Not always seen on ultrasound especially if collapsed; often more to patient right SOURCE Chou EH, Dickman E, Tsou PY et al., Ultrasonography for confirmation of endotracheal tube placement: A systematic review and meta-analysis. Resuscitation. 2015;90:97-103.
POINT OF CARE ULTRASOUND CONFIRMING TUBE PLACEMENT
TRACHEAL INTUBATION ESOPHAGEAL INTUBATION
Presentation Notes
First image shows the successful passing of the tube posterior to the trachea Note: ”Bullet Sign” which is the reverberation artifact posterior to the trachea when passing the tube Second image shows the ETT intubating the esophagus Note: a normally collapsed esophagus (patient right) being distended by hyperechoic circle (ETT) SOURCES: https://rebelem.com/pocus-for-endotracheal-tube-confirmation/
POST-RESCUSITATIVE CARE ACLS ROSC
Presentation Notes
This is 2015 AHA post-arrest care algorithm Important steps not to forget: Get a full set of vitals Secure the airway (if necessary) Treat hypotension Figure out why the patient coded (if necessary) 2015 ACLS Update: “If the patient has ROSC, post–cardiac arrest care should be started. Of particular importance are treatment of hypoxemia and hypotension, early diagnosis and treatment of ST-elevation myocardial infarction (STEMI)” (EVIDENCE: Class I, LOE B) 2015 ACLS Update: “and therapeutic hypothermia in comatose patients” (EVIDENCE Class I, LOE B)
POST-RESCUSITATIVE CARE
ALiEM ROSC Checklist SOURCE: https://www.aliem.com/2017/04/post-rosc-checklist/
• Confirm tube placement • Color capnography, End-tidal CO2, CXR, Ultrasound
• Decompress Stomach • Place NGT or OGT
AIRWAY
Presenter
Presentation Notes
Secure the airway Was the airway secured? If not, secure it. Options include: intubation, trach, need cricothyrotomy (temporizing) Confirm tube placement WHY: To ensure you haven’t inadvertently intubated the esophagus or tube has slipped during resuscitation Options including: color calorimetry, end-tidal CO2, Portable CXR, Ultrasound used at time of intubation Decompress the Stomach WHY: During resuscitation, bagging introduces air to the stomach which places patient at risk of aspiration Options including: Place NGT or OGT ALiEM ROSC Checklist SOURCE: https://www.aliem.com/2017/04/post-rosc-checklist/
• Optimize Breathing
• Ventilation • Goal EtCO2: 30-40 mmHg • Adjusting: Vt and/or RR
PEEP FiO2
Vt RR
Presentation Notes
How do we optimize breathing? If a patient is intubated, typically this involves ventilator management. Ventilator management is a lecture unto its own and also not the scope of this presentation. To very much simplify, clinicians use ventilators to regulate two processes: 1. Oxygenation (SpO2) 2. Ventilation (Co2 or H+/pH) They do so by regulating 4 variables that nearly all vents have in common: 1. PEEP 2. FiO2 3. Tidal Volume (Vt) 4. Respiratory Rate “Early hyperoxia exposure after resuscitation from cardiac arrest was independently associated with poor neurological function at hospital discharge.” SOURCE: Circulation. 2018 May 15;137(20):2114-2124. doi: 10.1161/CIRCULATIONAHA.117.032054. Epub 2018 Feb 1. ALiEM ROSC Checklist SOURCE: https://www.aliem.com/2017/04/post-rosc-checklist/
• How good is perfusion? • Check a blood pressure • Place foley for UOP as marker of perfusion • Consider pressor support and/or fluids as needed
• Consider access • Consider/place central line • Consider/place arterial line • Obtain/send labs
CIRCULATION
Presenter
Presentation Notes
2015 ACLS Update “Avoiding and immediately correcting hypotension (systolic blood pressure less than 90 mm Hg, MAP less than 65 mm Hg) during postresuscitation care may be reasonable” (EVIDENCE Class IIb, LOE C-LD). ALiEM ROSC Checklist SOURCE: https://www.aliem.com/2017/04/post-rosc-checklist/
• If not STEMI, consider cardiology consult/cath
CIRCULATION
Presenter
Presentation Notes
The 2013 American College of Cardiology Foundation/ American Heart Association (ACCF/AHA) guidelines have a Class I recommendation for performing immediate heart catheterization for percutaneous coronary intervention (PCI) for the management comatose patients with STEMI after OHCA [2]. SOURCE: 2015 ACLS Update: “Coronary angiography should be performed emergently (rather than later in the hospital stay or not at all) for OHCA patients with suspected cardiac etiology of arrest and ST elevation on ECG” (EVIDENCE Class I, LOE B-NR). In July 2015 the ACC/AHA have proposed and published an algorithm to stratify cardiac arrest patients who are comatose on presentation for emergent cath lab activation for coronary angiography and possible PCI SOURCE: https://www.acc.org/education-and-meetings/image-and-slide-gallery/media-detail?id=817da5f664194a02a4ec80b14c8d3a8f 2015 ACLS Update: “Emergency coronary angiography is reasonable for select (eg, electrically or hemodynamically unstable) adult patients who are comatose after OHCA of suspected cardiac origin but without ST elevation on ECG” (EVIDENCE Class IIa, LOE B-NR). 2015 ACLS Update: “Coronary angiography is reasonable in post–cardiac arrest patients for whom coronary angiography is indicated regardless of whether the patient is comatose or awake” (EVIDENCE Class IIa, LOE C-LD). ALiEM ROSC Checklist https://www.aliem.com/2017/04/post-rosc-checklist/
• Assess for neuro deficits • Response to pain, posturing, pupillary response
• Consider therapeutic hypothermia • Cool the patient to goal 32-36°C for at least 24 hours
DEFICITS
Presenter
Presentation Notes
2015 ACLS Update: “We recommend that comatose (ie, lack of meaningful response to verbal commands) adult patients with ROSC after cardiac arrest have TTM” (EVIDENCE: Class I, LOE B-R for VF/pVT OHCA) (EVIDENCE Class I, LOE C-EO for non-VF/pVT (ie, “nonshockable”) and in-hospital cardiac arrest). 2015 ACLS Update: “We recommend selecting and maintaining a constant temperature between 32°C and 36°C EVIDENCE: Class I, LOE B-R). 2015 ACLS Update: It is reasonable that TTM be maintained for at least 24 hours after achieving target temperature (EVIDENCE Class IIa, LOE C-EO). TTM=Targetted Temperature Management OHCA=Out of Hospital Cardiac Arrest
• Consider antibiotics
Presentation Notes
Small study showed that 38% of OHCA patients were bacteremic. Theoretical benefit for antibiotics SOURCE: Resuscitation. 2014 Feb;85(2):196-202. doi: 10.1016/j.resuscitation.2013.09.022. Epub 2013 Oct 12. Check with staff members to debrief May have opportunities to improvement May have been a traumatic experience for some providers (pediatric, severe trauma) May have been the first time somebody has seen a cardiac arrest/code. ALiEM ROSC Checklist SOURCE: https://www.aliem.com/2017/04/post-rosc-checklist/
CODE TERMINATION
Atibiotic Use Resuscitation. 2014 Feb;85(2):196-202. doi: 10.1016/j.resuscitation.2013.09.022. Epub 2013 Oct 12. The incidence and significance of bacteremia in out of hospital cardiac arrest. Coba V1, Jaehne AK2, Suarez A3, Dagher GA2, Brown SC2, Yang JJ4, Manteuffel J2, Rivers EP5. ALiEM ROSC Checklist https://www.aliem.com/2017/04/post-rosc-checklist/
REFERENCES
• See slide notes
EVIDENCE
• Throughout this lecture, AHA recommendations are graded on the following: • Descriptions of Class (Strength) of Recommendation • Description of Level of Evidence
Presenter
Presentation Notes
COR and LOE are determined independently (any COR may be paired with any LOE). A recommendation with LOE C does not imply that the recommendation is weak. Many important clinical questions addressed in guidelines do not lend themselves to clinical trials. Although RCTs are unavailable, there may be a very clear clinical consensus that a particular test or therapy is useful or effective.
CLASS (STRENGTH) OF RECOMMENDATION
LEVELS OF EVIDENCE
Slide Number 1

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THE CODING PATIENT: ACLS REVIEW