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Activate response team - call for HELP or 911 !        Remember the A-B-C-D Approach

Advanced Cardiac Life Support in Cardiac Arrest   

Asystole       See ACLS Protocol | Ventricular Fibrillation or Pulseless Ventricular Tachycardia  | Ventriciular Tachycardia with Pulse  

Asystole or PEA Rx (* Confirm true asystole in 2 leads)

*  Give 5 cycles of CPR [1 cycle of PCR = 30 compressions then 2 breaths (approx 2 minutes)]
     Check rhythm and pulse (any shockable rhythm) and confirm asystole in two leads.

*  The target of PEA Rx is correcting the underlying cause, not the rhythm.   

                                         

  • Start CPR for 5 cycles & Intubation & IV (See above Secondary Survey ABCD)

  • Epinephrine 1.0 mg IV/IO (Intraosseous) or 2-2.5 mg ETT (Endotracheal Tube route, not as effective) , may repeat every 3-5 minutes  

  • or Vasopressin 40 units IV/IO to replace the first or 2nd dose of epinephrine.  It can only be given once!  
    If vasopressin used, next dose of epinephrine is 10 minutes after vasopressin.  

  • Consider Atropine 1 mg IV push or IO, or 2-3 mg ETT, repeat every 3-5 minutes (Up to 3 doses;  Max: 0.04 mg/kg)

  • Consider termination of ACLS Rx if clinically indicated.

  • Transcutaneous pacing  (TCP) - not recommended for asystolic cardiac arrest, because several trials failed to show benefit for asystole.

*  Consider cessation of efforts after reasonable trial of ACLS therapy.  Chances of meaningful neurologic recovery with asystole is low.

Source: Circulation 2005;112. 2005 AHA Guidelines for CPR and ECC.


Look for and Correct Reversible Causes of Cardiac Arrest or Asystole/PEA   !  
H: Hypovolemia (hemorrhage or dehydration), Hypoxia, Hypokalemia, Hyperkalemia, Hypoglycemia, Hypothermia, Hydrogen ion (acidosis),
     Hyperthyroidism, Hypothyroidism.
T: Tension pneumothorax, Thrombosis (Coronary MI or Pulmonary PE), Tamponade (cardiac), Toxins (Digoxin toxicity, Beta blockers, TCA's), Trauma (Cardiac tamponade, Tension pneumothorax, aortic aneurysm rupture).  
*   Foreign body choking?

   

Approach to an unresponsive or cardiac arrest patient          Basic Life Support 2005 Algorithm  

Primary Survey ABCDs (Excerpt)

  1. Assess responsiveness by speaking loudly, or gently shaking the patient if there are no signs of trauma. - If NO MOVEMENT or RESPONSE, then
  2. Call for help (code blue or 911)/crash cart/AED (Automatic External Defibrillation) /Defibrillator if the patient is unresponsive - activate Emergency Medical Service.
  • A - Airway: Open airway (head tilt-chin lift or jaw thrust), look, listen, and feel for breathing.
  • B - Breathing: If not breathing, slowly give 2 rescue breaths that make chest rise
  • C - Circulation: Check pulse.
    If no pulse within 10 seconds, begin chest compressions CPR at 100/min, 1.5 - 2 inches depth (Give cycles of 30 compressions and 2 breathes, 30:2 ratio with unprotected airway).Consider precordial thump in witnessed arrest with no defibrillator immediately available.
    If there is definite pulse - Give 1 breath every 5 to 6 seconds (10-12 breathes per min), recheck pulse every 2 minutes.
  • D - Defibrillation: Attach monitor/AED. Assess rhythm. Search for and Shock V.Fib (Ventricular Fibrillation)/ Pulseless V.Tachycardia  
  • *   If no pulse or breathing, resume CPR, beginning with compression.

CPR Technique:

  • chest compressions at 100/min, 1.5 - 2 inches depth (cycles of 30 compressions and 2 breathes, 30:2 ratio with unprotected airway)
    5 cycles approximate 2 minutes
  • If there is a protected airway ET tube, give uninterrupted compressions 100/min with ventilation every 5-6 seconds, about 10-12 breathes/min)


Secondary Survey ABCDs (Excerpt)

  • A - Airway: Establish and secure an airway device.
  • B - Breathing: Ventilate with 100% O2.  Confirm correct airway device placement by clinical exam, end-tidal CO2 monitor, and O2 saturation monitor.
  • C - Circulation: Evaluate heart rhythm, check pulse and blood pressure; if pulseless, continue chest compressions 100/min (1 ventilation every 5-6 seconds with protected airway as ET tube in place = 10-12 breathes/min),
          obtain IV access and start IV fluid, give rhythm-appropriate medications.
  • D - Differential Diagnosis: Attempt to identify and treat reversible causes.
         H: Hypovolemia, Hypoxia, Hypokalemia, Hyperkalemia, Hypoglycemia, Hypothermia, Hydrogen ion (acidosis)
         T: Tension pneumothorax, Thrombosis (Coronary or Pulmonary-PE), Tamponade (cardiac), Toxins, Trauma.


Actions:
A - Airway & ET tube placement
B - Breathing, 100% O2, Mask   
C - Circulation, Pulse, Rhythm, CPR, IV Line , EKG Monitor , Oxymetry, BP, ECG
D - Defibrillation & Diff-Dx


* IO (Intraosseous Route)
   - Use IO access kit and a rigid needle, it serves as a rapid, safe, and reliable route for administration of drugs, crystalloids, colloids, and blood during resuscitation.  It is preferred over the ET (Endotracheal) route.  
* ET (Endotracheal Route)
   -
The typical dose of drugs administered via the ET route is 2 to 2.5 time the IV route, dilute the dose in 5 to 10 mL of water or normal saline, inject the drugs directly into the trachea.  
      Drugs: as Epinephrine, Vasopressin, Atropine, Lidocaine, Naloxone.

Ventricular Fibrillation or Pulseless Ventricular Tachycardia
Ventricular Fibrillation or Pulseless Ventricular Tachycardia Rx (Shock - CPR- Drug - CPR / Shock - CPR- Drug - CPR -  .....)  

 

  • Electrical defibrillation of Biphasic 120-200 Joules one shock (or Monophasic 360 Joules as needed); or AED device specific shock.  
    Resume 5 cycles of CPR  (30 compresssions-2 breathes in pt without advanced airway) immediately ! then Check rhythm .
  • Secondary ABCDs  [airway, breathing, circulation, differential dx]
    Place airway device (intubation) and confirm then secure; establish IV; CPR & attach cardiac monitor; search for reversible causes
  • Epinephrine 1 mg IV/IO, may repeat every 3-5 minutes (may also give 2-2.5 mg via ET Tube)
    or Vasopressin 40 units IV/IO
     (single dose only)
    Resume 5 cycles of CPR  (30 compresssions-2 breathes) immediately ! the Check rhythm - any shockable rhythm?

  • Electrical defibrillation of Biphasic 200 Joules one shock
    Resume 5 cycles of CPR  (30 compresssions-2 breathes in pt without advanced airway) immediately ! then Check rhythm.
  • Amiodarone 300 mg IV/IO push; may give 2nd dose of 150 mg in 3-5 min if VF/pulseless VT recurs;
    Max: 2.2 g/24h; Info: if pt stable, infuse 1 mg/min x6h then 0.5 mg/min x18h
    or Lidocaine about 1- 1.5 mg mg/kg (as 75-100 mg) IV, may repeat 0.5 - 0.75 mg/kg in 5-10 min (Max: 3 mg/kg);
    (may give 2-4 mg/kg via ET Tube);  Lidocaine IV Infusion 1-4 mg/min.  
    or Magnesium sulfate 1-2 gm in 10 mL D5W if suspect hypomagnesemia or Torsades de pointes
    Resume 5 cycles of CPR  (30 compresssions-2 breathes in pt without advanced airway) immediately ! then Check rhythm - any shockable rhythm?

  • Electrical defibrillation of Biphasic 200 Joules one shock
    CPR 5 cycles
    May repeat Epinephrine dose  

    Electrical defibrillation of Biphasic 200 Joules one shock
    CPR 5 cycles
    May try Lidocaine about 1- 1.5 mg mg/kg (as 75-100 mg) IV, may repeat 0.5 - 0.75 mg/kg in 5-10 min (Max: 3 mg/kg);
    (may give 2-4 mg/kg via ET Tube);  Lidocaine IV Infusion 1-4 mg/min.  
    or Magnesium sulfate 1-2 gm in 10 mL D5W if suspect hypomagnesemia or Torsades de pointes
    Resume 5 cycles of CPR  (30 compresssions-2 breathes in pt without advanced airway) immediately ! then Check rhythm

Procainamide  Loading dose: 15 mg/kg IV/IO over 30-60 min; 20-30 mg/min IV infusion (Max: 50 mg/min infusion; Total dose 17 mg/kg) for recurrent or refractory VT (with pulses), SVT.

May consider Na bicarbonate 1 ampule IV (~ 1 meq/kg IV) if suspect acidotic or prolonged arrest or hyperkalemic or tricyclic OD (best check ABG first)

* There is no evidence to date that routine use of any vasopressor drugs at any stage during Rx of pulseless VT, VF, or asystole increases rates of survival to hospital discharge.  
   But there is evidence that the use of vasopressors favors initial resuscitation with ROSC (Return of Spontaneous Circulation).

 

  ACLS  ADVANCED CARDIAC LIFE SUPPORT in CARDIAC ARREST  

 

 http://www.acls.net/     

 http://www.americanheart.org/presenter.jhtml?identifier=3035517   /  http://circ.ahajournals.org/content/vol112/24_suppl/    

       

2009