THE CHAIN OF SURVIVAL Sth EAS Gin ee Bie Ene Wii ate “gee” ae This is a concept which aims to improve the outcome for victims of cardiopulmonary arrest It involves a series of events which are interconnected to each other like the links of a chain. The 5 links in the Chain of Survival (Top figure) are described specifically as: (1) early access, (2) early CPR (3) early defibrillation, and (4) early ACLS., (5) Integrated post-cardiac arrest care. Based on the new 2015 AHA CPR/ECC Guidelines, they have recommended Separate Chains of Survival that identify the different pathways of care for patients who experienced Cardiac Arrest in the Hospital (IHCA) and Out of Hospital (OHCA) settings. (Left and right figures). The care for all post cardiac arrest patients (IHCA and OHCA) all converge in the hospital ICU setting. Patients who had an OHCA depend on their community for support where Lay rescuers must recognize the arrest, call for help and initiate CPR and apply Public AED protocols until EMS arrives and patient ultimately transferred to Hospital. The patients who had IHCA depend ona system of appropriate surveillance (e.g. rapid response or early warning system) to prevent cardiac arrest. All IHCA patients depend on a smooth multidisciplinary interaction among the department services and allied health providers including physicians, nurses, respiratory therapists and others. The First Link- Early Access = Awellinformed person - key in the early access link. = Recognition of signs of heart attack and respiratory failure = Call for help immediately if needed = Activate the Emergency Medical System Second Link - Early CPR = Life saving technique for cardiac & respiratory arrest = Chest compressions +/- Rescue breathing Why is early CPR important? = CPRis the best treatment for cardiac arrest until the arrival of Advanced Life Support. = prevents VF from deteriorating to asystole = may increase the chance of defibrillation = significantly improves survivalSTEPS IN BASIC LIFE SUPPORT FOR HEALTHCARE PROVIDERS IF YOU SEE A PERSON DROP DEAD, OR LOSE CONSCIOUSNESS, WITH PRESUMED SUDDEN CARDIAC ARREST, 4 CHECK AREA Survey the scene. NON-RESPONSIVE, SAFETY. ‘ecan tea of eet hepeeced, NO NORMAL BREATHING 2 CHECK UNRESPONSIVENESS. eer ane : Souewree,| G6tA Defibrillator! Quick check for normal breathing . ee caine AED! CALL FOR HELP: cencencr pee aes ‘Ambulance, ‘SERVICES Emergency Services, Get AEDDefibritiator! Doctor PULSE CHECIC ® Palpate for Carotid Pulse within 10 seconds = (atthe same time CHECK FOR BREATHING) © For trained healthcare providers only 1 1 1 1 I I 1 I a PULSE CHECK 1| After determining unconsciousness, 1 ' C-A-B ll + Fortrained healthcare providers only || ©. COMPRESSION Do chest ll + As short and quick as possible 1 compressions first ll + Pulse check not more than 10 seconds || A-AIRWAY Does the victim have an lt - ifunsure, proceed directly to CHEST 4 open airway (air passage | /COMPRESSIONS! that aliows the victim to N ! breathe)? B. BREATHING Is the victim breathing? ©c— Compression (to assist Crrcuation) After determining unconsciousness and calling for help, proceed immediately to do Cnest Compressions! 4) ‘Compress breast bone 2-2.4 inches deep (5-6 cm) Compress at a rate of 100 120 por minute or mare puna, 30 times inilaty i@) We ‘Allow the chest to return to its normal position + Place the heel of ‘Chest Compressions ‘victim's chest Hand Location tes Ed ©@ Give 30 Compressions © Compress breastbone 2~ 24 inches deep your hand on the center of the victim's chest. Put your other hhand on top of the first with your fingers interlaced. * (30 compressions should take 15-18 sec) * Count aloud 1,2, 3, 4, 5.6,7.8.9,10,11,12,19,44,15,16,17,18,19, 20,21,22,28,24.26,26 27.28.29, and ones" A> AIRWAY i258 nou lift method * Place one hand on the victim's forehead. Head Tilt Chin Lift Maneuveri a ‘mouth, Give 2 full breaths: (1 sec! breath) * Observe chest ise & fell listen & feel for escaping air : © Repeat cycles of 30 compressions & 2 breaths PULSE CHECK + RECHECK PULSE EVERY 2 MINUTES (equivatentto § cycles CPR) + Very brief pulse check— should take less than 10 seconds (at the same time check for normal breathing) + In case there is any doubt about the presence or absence of pulse, CONTINUE CHEST COMPRESSIONS + For trained healthcare providers only CONTINUE CPR UNTIL... *HELP ARRIVES. (Emergency Services, Ambulance, Doctor, AED) *PERSON IS REVIVED. ~ Wy ‘THE RECOVERY POSITION Maintain open airway & position the victim . victim with spontaneous respirations should be placed in the recovery postion if no cervical trauma is suspected. ® Placement in this postion consists of roling the Victim onto his or her side to help protect the wey. ‘es ae MEMORIZE THE STEPS! + Survey the soe + Check reponsiveness ~ ey hey are you ok? * Galfer heb Aavate EMS art RUPBEE NT Rar BUTREETe te seer + C= Chest Compression, 20x, Oba Zinghes deep push hard and fast Count 1-2°3-4-..26:27-28-9-and'4! A- Airway: head tilt chin lift + Breathing: 2 breathe (7 secondtreath Chest compressions 30% Continue cycles 30:2 compression-ventilation. Count 1-22 4."28-37-26-20-and 5 + [Quick check pulse every 2 mins — approximately 5 cycles) * hropihevey's eecande Utne? Sey Bow sup fo $3: ‘ablow. (12 cycles) + Unt: © ~ ENS antves (AED, doctor, ambulance) anenthae sigs of ieety oe Gay ipl enn) Scene Safety Make sure the environment is safe for rescuers and vitims Recognition of Check for responsiveness cardiac arest No breathing or only gasping (je, no normal bathing) No definite pulse fet within 10 seconds (Breathing and pulse check can be performed simultaneously in ess than 10 seconde) Activation of Ifyou are alone with no Witnessed collapse ay mobile phone, leave the vietim Follow steps for adults and adolescents onthe left response system | to-aclivate the emergency response system and get the Unwitnessed collapse AED before beginning CPR Give 2 minutes of CPR Otherwise, send someone and | Leave the victim to activate the emergency response system and begin CPR immediately; use the get the AED AED as soon as itis available Return to the chld or infant and resume CPR; use the AED as soon as itis avaiable anon 1 or 2rescuers Trescuer ventilation ratio 30:2 30:2 without advanced airway 2 or more rescuers 152 Compression Continuous compressions at a rate of 100-120/min ventilation ratio with advanced Give 1 breath every 6 seconds (10 breaths/min) airway Compression rate 100-120/min Compression Atleast 2 inches (5 cm)’ | Atleast one third AP diameter ] Atleast one third AP diameter depth of chest of chest About 2 inches (6 om) About 1/2 inches (4.0m) Hand placement | 2hands on the lower halfofthe | 2 hands or 1 hand (opional for rescuer breastbone (stemum) very small cild) on the lower | 2 fingers inthe center of the half of the breastbone (stemum) | chest, just below the nipple line 2 ormore rescuers 2 thumb-encircling hands in the center ofthe chest, just below the nipple line Chest recoil ‘Allow fl recoil of chest after each compression; do not lean on the chest afer each compression Minimizing Limit intemruptions in chest compressions to less than 10 seconds interruptions *Compression depth should be no more than 2.4 inches (6 cm). ‘Abbreviations: AED, automated external defibritator, AP, anteroposterior; CPR, cardiopulmonary resuscitationBLS Healthcare Provider Adult Cardiac Arrest Algorithm—2015 Update No breathing or only gasping, no pulse By this time in all scenarios, emergency response system or backup is activated, and AED and emergency equipment are retrieved or someone is retrieving them. (©2015 American Heart AssocationADVANCED CARDIAC LIFE SUPPORT ACLS includes 2S Basic Life Support (BLS) The use of adjunctive equipment and special techniques for establishing and maintaining effective ventilation and circulation. Electrocardiographic (ECG) monitoring and arrhythmia recognition. Establishment and maintenance of intravenous (IV) access. Therapies for emergency treatment of patients with cardiac or respiratory arrests (including stabilization in the post arrest phase) and, Treatment for patients with suspected Acute Myocardial Infarction and stroke. ACLS includes the ability to perform these skills, and the knowledge, training, and judgment about when and how to use them. The Algorithm Approach to Emergency Cardiac Care (ECC) The following clinical recommendations apply to all treatment algorithms. First, treat the patient not the monitor. Algorithms for cardiac arrest presume that the condition under discussion continually persists, that the patient remains in cardiac arrest, and that CPR is always performed. Apply different interventions whenever appropriate indications exist Adequate airway, ventilation, oxygenation, chest compressions, and defibrillation are more important than administration of medications and take precedence over initiating an intravenous line or injecting pharmacologic agents. Several medications (epinephrine, lidocaine, and atropine) can be administered via the endotracheal tube, but the dose must be 2 — 2.5 times the intravenous dose. (Use a catheter or suction tip which should be passed beyond the tip of the endotracheal tube. Dilute with water instead of NSS for endotracheal route. ) With a few exceptions, intravenous medications should always be administered rapidly, in bolus method. After each intravenous medication, give a 20-30 ml bolus of intravenous fluid and immediately elevate the extremity. This will enhance delivery of drugs to the central circulation, which may take 1-2 minutes. Last, treat the patient, not the monitor.SIMPLE APPROACH TO ECG RECOGNITION OF THE ARRHYTHMIAS DURING ACLS. Steps in the Systematic ECG Interpretation of the ACLS Rhythms + Regularity? Is it regular or irregular? Rate? Is it fast or slow or normal? Rhythm? Is it Sinus? Check the waveforms. Is there a P wave followed by a QRST? Measure the Intervals: PR, QRS, QT Is there a Rhythm abnormality? Correlate clinically. SINUS RHYTHM + There is a P wave, followed by a QRS complex at a regular rhythm and rate of 60-100 bpm SINUS BRADYCARDIA * There is a regular P wave followed by a regularly occurring QRST, but the rate is < 60 bpm SINUS TACHYCARDIA * There is a regular P wave followed by a regularly occurring QRST, but the rate is > 100 bpmSLOW ACLS RHYTHMS- BRADYCARDIA * Sinus bradycardia « Sinus pause * Escape rhythms: > Junctional rhythm > Idioventricular rhythm + Heart blocks > 1% degree AV block >» 2” degree AV block * Mobitz | or Wenckebach * — Mobitz II > 3° degree or complete AV block SINUS PAUSE (SINUS ARREST) + There is a P wave followed by a QRST, but at some point there is irregularity and slowing of the heart rate, and the ECG shows no P wave and no QRS. In other words, it simply PAUSED! Pause JUNCTIONAL RHYTHM This is an escape rhythm; Impulses come from the AV node * Usually a regular slow heart rate, < 60 bpm (rate is usually between 40-50 bpm). QRS are narrow. There are no discernible P waves (actually the P waves are inverted or buried wiin QRS or follows the QRS) Junctional IDIOVENTRICULAR RHYTHM Another escape rhythm; Impulse is ventricular in origin * Regular slow heart rate, < 40 bpm (usually between 20-40 bpm), wide QRS and no discernible P waves; QRS duration > 0.10 sec Idioventricular FIRST DEGREE AV BLOCK + There is a normal regular P wave, followed by a regular QRS complex, but the PR interval is > 0.20 sec (>5 small squares in the ECG strip) 1* deg AV blockSECOND DEGREE AV BLOCK MOBITZ I (WENCKEBACH) * Progressive lengthening of the PR interval followed by intermittent dropped beats (a P wave NOT followed by a QRS) 2° deg AV block Mobitz | SECOND DEGREE AV BLOCK MOBITZ II + Fixed PR interval (NO progressive lengthening) w/ intermittent dropped beats ete : | E faeisisb rl ie Pt afetet = Important point: 2" degree AV block is ALWAYS IRREGULAR and usually presents with GROUP BEATING. 2:1 AV BLOCK + 2P waves for every 1 QRS complex (every other P wave is blocked) 2:1 AV block HIGH GRADE AV BLOCK * Atrio-ventricular conduction ratio is 3:1 or higher * 3:1, 4:1, 5:1 AV block and anything higher is called High Grade AV block High grade AV block THIRD DEGREE AV BLOCK OR COMPLETE HEART BLOCK * No recognizable consistent or meaningful relationship between atrial and ventricular activity (there is ATRIO-VENTRICULAR DISSOCIATION) + There are regularly occurring P waves, there are regularly occurring QRS complexes, but they are not related to each other (in other words, they are dissociated) * QRS morphology is constant; QRS rate constant (15-60 beats/min); atrial rate is usually faster than ventricular rate, but the atrial and ventricular rhythms are independent of each other; ventricular rhythm is maintained by a junctional or idioventricular escape rhythm or a ventricular pacemakerCHB ae 7 c SEE eee me |CHB Complete heart block with a ventricular escape rhythm FAST ACLS RHYTHMS - TACHYCARDIA = Sinus tachycardia Supraventricular tachycardia Atrial fibrillation Atrial flutter Multifocal atrial tachycardia Ventricular tachycardia TACHYCARDIA - divided into Narrow complex and Wide complex Tachycardia Narrow QRS Complex Tachycardia Wide QRS Complex Tachycardia (QRS duration < 0.12 secs) (QRS duration 20.12 secs ) TACHYCARDIA Narrow QRS Wide QRS Regular rhythm Grossly Irregular Regularrhythm Irregular Rhythm Rhythm SVT with _Preexcited AF Torsade vt aberrancy AF with aberrancy MAT AF Sinus Paroxysmal SVT Tach (ceentrant) UrSUPRAVENTRICULAR TACHYCARDIA + Regular narrow QRS complex tachycardia, usually with sudden onset and termination, with a rate of 150-250 beats/min + No discernible P waves + P waves are generally buried in the QRS complex. Often, P wave is seen just prior to or just after the end of the QRS and causes a subtle alteration in the QRS complex that results in a pseudo-S or pseudo-r ATRIAL FIBRILLATION * — Irregularly irregular narrow complex tachycardia with no discernible P waves * Chaotic irregular atrial fibrillatory waves ATRIAL FLUTTER * Narrow complex tachycardia, regularity and rate depends on the degree of AV conduction * Atrial rate = 220-350/min (P as flutter waves); Ventricular response usually 150-180 bpm * — Look closely for your beautiful sawtooth flutter wavesMULTIFOCAL ATRIAL TACHYCARDIA + Impulses originate irregularly and rapidly at different points in the atrium + Irregularly irregular narrow complex tachycardia with varying P wave, PR, PP and RR intervals, and 3 or more different P wave morphologies MAT VENTRICULAR TACHYCARDIA + Atleast 3 consecutive PVC's + Rapid, bizarre, wide QRS complexes firing in succession at a rate of >100 bpm; usually no discemible P wave ARREST RHYTHMS - there are only 4: * Asystole * Pulseless electrical activity * Ventricular fibrillation + Pulseless VT ASYSTOLE + The easiest rhythm to identify! There is no discernible electrical activity. ECG shows a flat line. The patient is in CARDIAC ARREST! Asystole VENTRICULAR FIBRILLATION * Associated with coarse or fine chaotic undulations of the ECG baseline. There are no P waves and no true QRS complexes. The rate is indeterminate. The patient is in CARDIAC ARREST!PULSELESS VENTRICULAR TACHYCARDIA * Rapid, bizarre, wide QRS complexes firing in succession at a rate of >100 bpm, but the patient has NO PULSE and NO BLOOD PRESSURE. Patient is also in CARDIAC ARREST! Treat as VF! PULSELESS ELECTRICAL ACTIVITY + ECG shows an organized electrical activity (NOT VF or pulseless VT); either a narrow QRS or wide QRS rhythm; fast (>100 beats/min) or siow (<60 beats/min). + There is organized cardiac electrical impulses but no effective myocardial contraction is produced (also known as “electromechanical dissociation”); patient has ZERO blood pressure and ZERO heart rate, in other words, PATIENT IS IN CARDIAC ARREST! APSE i Hi PEA ECG of a patient with PEA- may show either bradycardia (commonly idioventricular or junctional) or tachycardia (other than VT) but the patient has NO pulse and is in cardiac arrest. ISCELI OUS A‘ HYTHI WOLFF PARKINSON WHITE (WPW) ECG (PREEXCITATION) + ECG shows short PR interval (<0.12 secs), delta wave (upward slurring of the QRS complexes as indicated by arrows) and wide QRS complexes. These patients have an extra accessory pathway or bypass tract that may conduct impulses rapidly. They may present with supraventricular tachycardia (usual narrow QRS tachycardia) or with preexcited rapid atrial fibrillation which presents as irregular wide complex tachycardia (see below) and may be mistaken as VT or VF. In reality, such rapid preexcited AF may actually lead to VF and sudden death. WPWPREEXCITED RAPID ATRIAL FIBRILLATION + Rapid atrial fibrillation in a patient with WPW syndrome presents as wide complex tachycardia that may look like VF/VT. Just remember the acronym F-B+I: Fast-Broad- Irregular for preexcited tachycardia. Important point to remember: DO NOT GIVE digoxin or calcium channel blockers because these may convert the arrhythmia into VF! What to do: either IV procainamide, IV amiodarone, or Cardiovert the patient! Hh hf fh my ul “fei Heel ais AYALA ALAA AML A lh WA PACEMAKER RHYTHM {| wew AF + ECG ofa patient with an artificial pacemaker which is inserted for significant bradycardia. Tracing shows a sharp pacemaker potential or spike (as indicated by the arrows) followed by a wide QRS complex which indicate “capture” of the ventricle. TORSADE POINTES Paced * Polymorphic VT occurring in patients with long QT interval. ECG shows also irregular bizarre rapid wide QRS complexes, hence also Fast-Broad-Irregular (F-B-1). But take note that the QRS complexes seem to change from a positive to a negative axis around a certain point (twist around a point). Torsade pointes means “twisting of the points’. -— TDPFOLLOW THE SIMPLE ALGORITHM BELOW FOR EASY AND RAPID RECOGNITION OF THE ACLS RHYTHMS HR <60 ‘SLOW Regularity a No P wave P-QRS Narrow QRS) Wide QRS Group beating sin a af + 53 & nus : = Junetonal] | Idio- 3rd degree | Era, | ventricular} |__AV Block Slow AF ‘AV Block HR > 100 Irregular + 4 (Cewave } [Nop Wave ) (Cewave } (Nop Woe ) (Flutter waves Plors Different P {norphologies ¥ ie ¥ ¥ Sinustach] {svt} (wat) (RapidAF) (Atrial flutterDEFIBRILLATION Defibrillation * therapeutic use of electric current delivered in large amounts over very brief periods of time. * temporarily “stuns” an irregularly beating heart and allows more coordinated contractile activity to resume. * _ termination of VF for at least 5 seconds following the shock Rapid defibrillation is the major determinant of survival in cardiac arrest due to ventricular fibrillation (VF) Early defibrillation is critical for several reasons: 1. Ventricular fibrillation (VF)- most frequent initial rhythm in sudden cardiac arrest (SCA) 2. Treatment of VF is electrical defibrillation 3. Probability of successful defibrillation diminishes rapidly overtime 4. VF tends to deteriorate to asystole within a few minutes 5. CPR prolongs VF, delays the onset of asystole, and extends the window of time during which defibrillation can occur. In witnessed arrest, defibrillation should be applied immediately after the onset of VF, i.e. before the heart becomes anoxic and acidotic, which would make successful defibrillation and resumption of cardiac activity less likely. Defibrillation is accomplished by passage of sufficient electric current (amperes) through the heart. Current flows determined by the energy chosen (joules) and transthoracic impedance (ohms), a resistance to current flow. Factors that determine transthoracic impedance include: energy selected electrode size paddle-skin coupling material (gel/cream or saline-solution gauze) number and time interval of previous shocks phase of ventilation distance between electrodes (chest size) paddle electrode pressure. PE Oh Pe NS oe ELECTRODE POSITION Electrodes should be placed to maximize current flow through the myocardium. The standard placement is one electrode just to the upper part of the stemum below the clavicle and the other to the left of the nipple with the center of the electrode in the mid-axillary line. Care should be taken that the electrodes are well separated and that paste or gel is not ‘smeared between the paddles on the chest. Otherwise, current may flow preferentially along the chest wall, “missing” the heartENERGY REQUIREMENTS The recommended energy for the first and succeeding defibrillation attempts is 360J monophasic or 200J biphasic. CPR should be continued immediately after defibrillation, for 2 minutes, followed by rhythm check. Biphasic waveform defibrillation with shocks of < 200J is safe and has equivalent or higher efficacy for termination of ventricular fibrillation (VF) compared with higher-energy monophasic — waveform shocks. SHOCK ENERGIES + The optimal energy for first shock biphasic waveform defibrillation has not been determined. + Biphasic: 120-200J (Class | LOE C) * _ If Manufacturer's recommendation not known: Use maximal dose (Class IIb) * Monophasic: 360J PEDIATRIC + VF is uncommon in children + 2-4 Joules/kg is recommended SYNCHRONIZED CARDIOVERSION Synchronized cardioversion is delivery of electrical shock timed to the peak of the QRS complex. Synchronization of delivered energy reduces the possibility of induction of VF, which can occur when a shock impinges on the relative refractory period of the cardiac electrical activity. Thus, synchronization is recommended for unstable supraventricular tachycardia, atrial fibrillation, atrial flutter, and monomorphic ventricular tachycardia. ENERGIES FOR SYNCHRONIZED CARDIOVERSION * Atrial flutter and SVT (narrow regular) - 50 J to 100 J (monophasic or biphasic) + Atrial fibrillation (narrow irregular) - 120J to 200J (biphasic) OR 200J (monophasic) * Monomorphic VT (wide regular) - 100J + Polymorphic VT (wide irregular) — defibrillation dose, NOT SYNCHRONIZED TECHNIQUE FOR EXTERNAL ELECTRICAL DEFIBRILLATION Turn the main power switch on. Turn the synchronize switch of the defibrillator off. 2. Set the energy to be delivered at 360J (for adults) or equivalent biphasic waveform shock at 200J. Lubricate the paddle with electrode gel. Charge paddles. Someone should continue CPR while you are charging the defibrillator. Interrupt chest compressions (preferably 10 seconds, maximally 20 seconds) for the defibrillation. Place one paddle just to the right of the upper sternum below the right clavicle, the other paddle just below and to the left of the left nipple as indicated in the paddles. 6. Apply firm pressure with paddles against the chest to reduce lung volume and electric resistance. 7. Confirm ECG diagnostic of VT or VF (Pulseless ventricular tachycardia or ventricular fibrillation) 8. Clear the area with no one touching the patient. Shout: “fam going to shock the patient on three! One I'm clear! Two you are clear! Three everybody clear!” eae9. Discharge the defibrillator by pushing the appropriate triggers on the paddles simultaneously. 10. After defibrillation, immediately continue CPR. 11. Check rhythm after each 5 cycles (2mins) of CPR and proceed accordingly. (See VF/VT Algorithm) TO DO SYNCHRONIZED CARDIOVERSION, tum the “Synchronize” switch or “SYNC” ON and select the desired energy for cardioversion. Continue with steps 3 to 9 above. When discharging, place the paddles on the chest longer, and firmly. IMPORTANT NOTES: e Pulseless VT is treated as VF > Defib! * Unstable monomorphic (regular) VT with pulse synchronized cardioversion (100J, increase dose if no response to the 1* shock) * Unstable polymorphic (irregular) VT w/ or w/o pulse- Defib! If there is any doubt if monomorphic or polymorphic VT in unstable patient, DO NOT DELAY shock delivery, provide high energy unsynchronized shocks (ie, defibrillation doses)Adult Cardiac Arrest Algorithm—2015 Update Start CPR * Give oxygen CPR 2 min + Treat reversible causes CPR2 min + Amiodarone + Treat reversible causes et { Gotosor7 cea | + ifno signs of return of | spontansous circulation | (RO8Q, goto 10 oF 14 k © ITROSC, go to Post-Cardiac Arrest Care (© 2015 American Heart Associanon Soe + Trromboste, corenary Een + Push hard fat least 2 inches: [5 emp and fast (100-t20¢/minp and alow complete chest recol. + Minimize ntemuptions in ‘compressions. + cid excessive veiatin, ‘+ Rotato comprecsor every 2 mikes, oF soena: fatigued + Iino advanced airway, 30:2 compression-ventlation PETCO, <10 mm Hg, attempt to improve CFR quality. + Intraarteral pressure ~ Wreloxation phase (aia- totic) pressure <20 mm Hg, attempt to improve CPR ‘ual, Ee * Biphasic: Manufacturer recommendation (o, tial dose of 120-200 Jf unknown, Use maximum avatebl. ‘Secon and subsequent doses ‘should be equivalent, and higher ‘doses may be considered. ‘+ Monophaste: 860.1 Drug Therapy eee + Endotrachel intubation or ‘supraglttic advanced airway + Wavetom capnography or ‘capnemetry to oniem and monitor ET tube placement + Once advanced alway n lace, give | breath every & seconds (10 breaths/min) with continuous Chest compressions Petco, typi 240 mm Ha) + Sportanoous arena pressure ‘waves th intra aetna rmoniorng Sees ‘+ Hypovoiemia + Hypoxia + Hycrogen fon (acidosis) + Hypo-Mnyperkaleria + Hypothermia » Tension preumothorax + Tamponad, cardiac + Toxne * Thrombosis, puimonsryTACHYCARDIA ALGORITHM ‘Assess appropriateness for clinical condition Heart rate typically > 150/min if tachyarrhythmia. Identify and treat undertying cause + Maintain patent zinway; assist breathing as necessary + Oxygen (if hypoxemic) + Cardiac monitor to identi rhythm; monitor blood pressure and oximetry Porsistent tachyarthythmia causing” + Hypotension? + Acutely altered mental status? + Signs of shock? + Ischemic chest discomfort? foute heart failure? Synchronized cardioversion + Consider sedation + if regular narrow complex, consider adenosine + IV access and 12ead ECG if available + Consider adenosine only if regular and monomorphic + Consider antiaythmic infusion + Consider expart consultation Wide QRS? 2.0.12 secong + 1V access and 124eed ECG if available + Adenosine (if regular) + B-Blocker or calcium channel blocker + Consider expert consultation DosesiDetalls ‘Synchronized Cardioversion inal recommended doses: + Narrow regular: 50-100 3 x + Narrow irregular. 120-200 J biohasieor 200 J monophasic + Wide regular 100) + Wide irregutar: ‘efbltation dose (NOT synchronized) Adenosine IV Dose: “Fim dose: 6 mg apd push folow hws [3 fash Second dose: 2g f requied. ‘Wide-QRS Tachycardia Procainamide IV Dose: Dag —— anmythmia suppressed, hypotension ensues, ‘ORS duration inceases > 50%, or maximum dose 17 mgikg given. Maiienance infusion ‘tA mginn, Avoid it prolonged QT or CHE. ‘Amiodarone V Dose: “Fist cose: 150 mg over 1Ominutes RRopoat 2s noodod it V7 recurs, Folowed by maintenance infusion of mgimin for fist 6 hous Yall IV Dose. Avoid ifprolonged CT Figure reprinted from 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science, Circulation vol 122, no. 18, supplement 3BRADYCARDIA ALGORITHM Adult Bradycardia (With Pulse) ‘Assess appropriateness for clinical condition, Heart rate typically. < 50/min if brasyarthythmia, Identify and treat underlying cause + Maintain patent airway; assist breathing 2s nevessary + Oxygen (if hypoxemic) + Cardiac monitor to identify rhythm; monitor blood pressure and oximetry = \Vacoess + 12ead ECG if available; don't delay therapy Persistent bradyarrhythmia causing + Hypotension? + Acutely altered mental status? + Signs of shock? + Ischemic chest discomfort? Acute heart failure? Monitor and observe iropine If atropine ineffective: > + Trascutaneous pacing Pe OR: Fist dose: 0.5 mg botus + Dopamine infusion Repeat every -5 oR minutes + Epinephrine infusion ‘Maximum: mg Dopamine IV infusion: 2-10 meg pes minute ine NY Consider: — + Expert consultation 2-10 meg per minute + Trensvenous pacing Figure reprinted from 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science, Circulation vol 122, no. 18, supplement 35 z POST-CARDIAC ARREST CARE ALGORITHM Consider induced hypothermia Coronary repurfusion Return of Spontaneous Circulation (ROSC) Optimize ventiiation and oxygenation + Maintain oxygen saturation > 94% + Consider advanced airway and waveform ccapnography + Do not hyperventilate ‘Treat hypotension (SBP <90 mm Hg) + IVNIO bolus + Vasopressor infusion * Consider treatable causes + 12-Lead ECG Advanced critical care DosestDetails ‘entlation/Oxygenation Avoid excessive vention Siat at 10-12 breathsinin and tite to target PetCo, of 36-40 mm Hg, Wen feasible, trate id, to minimum necessary 0 achieve SPO, 204i Bolus 4-2 normal saline oF lactated Ringer's. ‘inducing hypothermia, may use 4°C id, Epinephrine IV Infusion (0.1.0.5 moghkg per minute (io 704g adult: 7-35 meg per minute) Dopamine V Infusion 5-10 meg/tg per minuto Norepinephrine IV Infusion 0.4.05 mogikg per minuté (in 704g adult: 7-35 mog ‘per minute) Reversible Causes: = Hypovlemia Hypoxia = Hycrogen on (aco) + Hypo-Inyperkalemia “Hypoteria = Tension pneumothorax + Temponade, cardiac “Toxine + Thrombosis, pulmonary “Thromboss, coronary Figure reprinted from 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science, Circulation vol 122, no. 18, supplement 3