| 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)
-
Assess responsiveness by speaking
loudly, or gently shaking the patient if there are no signs of trauma.
- If NO MOVEMENT or RESPONSE, then
-
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 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).
|
TOC |
STAT |
ACLS Protocol |
V.FIB
