Pulseless arrest: Difference between revisions

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*[[PE|Thrombosis, pulmonary]]
*[[PE|Thrombosis, pulmonary]]
*[[ACS|Thrombosis, coronary]]
*[[ACS|Thrombosis, coronary]]
Sound knowledge of H’s and T’s<ref>https://acls.com/free-resources/pea-asystole/reversible-causes-of-cardiac-arrest-hs-and-ts</ref> is especially beneficial because it not only helps to keep a patient alive during cardiac arrest, but it can also potentially prevent cardiac arrest in adults and children if these conditions are treated as soon as they are observed. People who are prone to cardiac arrhythmias could most likely have one of these underlying conditions. However, should a person go into cardiac arrest, resuscitation should take priority over trying to determine if one of these conditions is present.


===PEA Evaluation by QRS===
===PEA Evaluation by QRS===

Revision as of 13:39, 15 March 2016

Immediate

  1. Start CPR
  2. Give oxygen
  3. Attach monitor/defibrilator
  4. Rhythm shockable?

V-Fib and Pulseless V-Tach (Shockable)

  • Shock as quickly as possible and resume CPR immediately after shocking
    • Biphasic - 200J
    • Monophasic - 360 J
  • Give Epi 1mg if (shock + 2min of CPR) fails to convert the rhythm
  • Give antiarrhythmic if (2nd shock + 2min of CPR) again fails
    • 1st line: Amiodarone 300mg IVP w/ repeat dose of 150mg as indicated
    • 2nd line: Lidocaine 1-1.5 mg/kg then 0.5-0.75 mg/kg q5-10min
    • Polymorphic V-tach: Magnesium 2g IV, followed by maintenance infusion

Asystole and PEA (Non-Shockable)

PEA.png
  • Epi 1mg q3-5min
  • Three major mechanisms of PEA (3 & 3 Rule)
  1. Severe Hypovolemia
  2. Obstruction
  3. Pump Failure

Treatable ACLS Conditions (H's and T's)

Sound knowledge of H’s and T’s[1] is especially beneficial because it not only helps to keep a patient alive during cardiac arrest, but it can also potentially prevent cardiac arrest in adults and children if these conditions are treated as soon as they are observed. People who are prone to cardiac arrhythmias could most likely have one of these underlying conditions. However, should a person go into cardiac arrest, resuscitation should take priority over trying to determine if one of these conditions is present.

PEA Evaluation by QRS

Differential based on QRS being narrow or wide and aided by ultrasound

QRS Narrow

Mechanical RV Problem – Ultrasound should show hyperdynamic LV and potential cause

QRS Widened

Metabolic LV Problem – Ultrasound should show hypokinetic LV

General

  • A (adjunct) - Place oropharyngeal airway
  • B (breathing) - place on Ventilator to assure slow ventilation rate (attach to BVM mask)
    • 10-12 bpm, 500cc tidal volume, Fio2 100%
  • C (compressions) - Switch out providers q pulse check; use metronome
  • D - defibrillation
    • Ok to shock during compressions if wearing gloves and using biphasic device
  • A (advanced airway)
    • Use LMA (NOT ET tube - no break in compressions required)
  • B (advanced breathing)
    • Connect LMA to Ventilator
      • Pressure control 20, RR 10, insp rate 1.5-2s
  • C (advanced circulation)
    • Place IO instead of central line
  • D (differential)

Refractory Ventricular Fibrillation

A patient is considered refractory after ≥3 defib, ≥3mg epi, and 300mg amio

Esmolol for Failure of Standard ACLS[2]

  1. Place a second set of defib pads in an alternative location on the chest
  2. Continue CPR
  3. Deliver 360J simultaneously from both defibrillators
  4. Continue CPR
  5. Give Esmolol bolus at 0.5mg/kg and start drip at 0.1mg/kg
  6. Deliver 360J simultaneously from both defibrillators
  7. Continue CPR

Fibrinolytics

  • ACLS 2010 does not yet recommend routine thrombolytics (Class III)
  • CHEST 2012 and ACLS 2010 recommends in acute PE or high suspicion[3]
    • Class IIc and Class IIa, respectively
    • 2 hr infusion time recommended over long, 24hr (CHEST Class IIc)
  • tPA in PEA - regimen considerations differ based on study[4]
    • If CPR for 15 min with standard ACLS not obtaining ROSC, consider tPA
    • Alteplase 0.6 mg/kg IV push x1 given over 15 min (± heparin 5000 unit bolus), and then repeated 30 min after if still no ROSC[5]
    • Heparin may be bolused with tPA or after ROSC obtained
    • Max doses of 50mg may be as efficacious as 100mg
    • Consider at least 20min of CPR after last dose of tPA before ending code

See Also

References

  1. https://acls.com/free-resources/pea-asystole/reversible-causes-of-cardiac-arrest-hs-and-ts
  2. Driver BE, Debaty G, Plummer DW, et al. Use of esmolol after failure of standard cardiopulmonary resuscitation to treat patients with ventricular fibrillation. Resuscitation. 2014; 85(10):1337-1341.
  3. Kearon C et al. Chest 2012; 141 (2)(suppl):e419s-e494s. Vanden Hoek TL et al. Circulation 2010; 122 (suppl):S829-S861.
  4. Janata K et al. Resuscitation 2003;57:49-55.
  5. Böttiger BW et al. Lancet 2001;357:1583-5.
  • Desbiens NA. Simplifying the diagnosis and management of pulseless electrical activity in adults: a qualitative review. Critical Care Medicine. 2008;36(2):391–396.
  • AHA 2010 ACLS Guidelines
  • EMCrit Podcast #31