Dr hashemian CPR

Seyed Mohamadreza Hashemian.MD.FCCMFCCS consultant

Associate professor of [email protected]

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92 year old man in the nursing home. Found in cardiac arrest. No DNR present. The cardiac monitor shows this rhythm:

what is the appropriate next step in treating this patient?

A. Begin CPR, initiate vascular access and manage the airway

B. Immediately defibrillate and then resume CPRC. Begin CPR and prepare to pace the rhythmD. Do not start resuscitation

5. What is the appropriate ratio of compressions to breaths in adult CPR with 2 rescuers?

6. What medication(s) would be appropriate for treating this rhythm?

Building Blocks of CPR.

Travers A H et al. Circulation. 2010;122:S676-S684

Copyright © American Heart Association, Inc. All rights reserved.

ACLS Cardiac Arrest Algorithm.

Neumar R W et al. Circulation. 2010;122:S729-S767


ACLS Cardiac Arrest Circular Algorithm.



Bradycardia Algorithm.



Tachycardia Algorithm.



is the primary drug used in the pulseless arrest algorithm. It is used for its potent vasoconstrictive effects and also for its ability to increase cardiac output. Epinephrine is considered a vasopressor.

Indications for ACLS

1.Vasoconstriction effects: epinephrine binds directly to alpha-1 adrenergic receptors of the blood vessels (arteries and veins) causing direct vasoconstriction, thus, improving perfusion pressure to the brain and heart.2.Cardiac Output: epinephrine also binds to beta-1-adrenergic receptors of the heart. This indirectly improves cardiac output by:

o Increasing heart rateo Increasing heart muscle contractilityo Increasing conductivity through the AV node

Epinephrine

Epinephrine is used in the pulseless arrest algorithm as a direct IV push and also in the bradycardia algorithm as an infusion..

RoutesDuring ACLS, epinephrine can be given 3 ways:

intravenous; intraosseous, and endotracheal tube

DosingIntravenous Push/IO: 1mg epinephrine IV is given every 3-5 minutes.IV infusion for bradycardia: 1mg epinephrine is mixed with 500ml of NS or D5W. The infusion should run at 2-10 micrograms/min (titrated to effect).IV infusion for post-cardiac arrest hypotension: The dosing is 0.1-0.5 mcg/kg/min (for example a 70kg adult: 7-35 mcg/min would be given).Endotracheal Tube: 2-2.5mg epinephrine is diluted in 10cc NS and given directly into the ET tube.

Epinephrine should be used with caution in patients suffering from myocardial infarction since epinephrine increases heart rate and raises blood pressure. This increase in HR and BP can

increase myocardial oxygen demand and worsen ischemia.

Note: There is no clinical evidence that the use of epinephrine, when used during cardiac arrest, increases rates of survival to discharge from the hospital. However, studies have shown that epinephrine and vasopressin improve rates of ROSC (return of spontaneous circulation).

is a primary drug used in the pulseless arrest algorithm. In high concentrations, it raises blood pressure by inducing moderate vasoconstriction, and it has been shown to be more effective than epinephrine in asystolic cardiac arrest (Wenzel V, Krismer AC, Arntz HR, Sitter H, Stadlbauer KH, Lindner KH (January 2004). “A comparison of vasopressin and epinephrine for out-of-hospital cardiopulmonary resuscitation”. N. Engl. J. Med. 350 (2): 105–13. doi:10.1056/NEJMoa025431. PMID 14711909.)

One major indication for vasopressin over epinephrine is its lower risk for adverse side effects when compared with epinephrine.

With epinephrine, some studies have shown a risk of increased myocardial oxygen consumption and post arrest arrhythmias because of an increase in heart rate and contractility (beta 1 effects). Vasopressin also is thought to cause cerebral vessel dilation and theoretically increase cerebral perfusion.

Trivia: Another name for vasopressin is antidiuretic hormone (ADH).

Vasopressin

RoutesVasopressin may be given IV/IO or by endotracheal tube.

Dosing40 units of vasopressin IV/IO push may be given to replace the first or second dose of epinephrine, and at this time, there is insufficient evidence for recommendation of a specific dose per the endotracheal tube.

In the ACLS pulseless arrest algorithm, vasopressin may replace the first or second dose of epinephrine.

is considered a class III antiarrhythmic agent and is used for various types tachyarrhythmias. Because of its associated toxicity and serious side-effects it should be used cautiously and care should be taken to ensure that cumulative doses are not exceeded.


Amiodarone is an antiarrhythmic that is used to treat both supraventricular arrhythmias and ventricular arrhythmias.

The mechanism of action of amiodarone remains unknown, but within the framework of ACLS, amiodarone is used primarily to treat ventricular fibrillation and ventricular tachycardia that occurs during cardiac arrest and is unresponsive to shock delivery, CPR, and vasopressors

Amiodarone

Amiodarone is considered a class III antiarrhythmic agent and is used for various types tachyarrhythmias. Because of its associated toxicity and serious side-effects it should be used cautiously and care should be taken to ensure that cumulative doses are not exceeded.


Amiodarone is an antiarrhythmic that is used to treat both supraventricular arrhythmias and ventricular arrhythmias.

The mechanism of action of amiodarone remains unknown, but within the framework of ACLS, amiodarone is used primarily to treat ventricular fibrillation and ventricular tachycardia that occurs during cardiac arrest and is unresponsive to shock delivery, CPR, and vasopressors.

Amiodarone should not be used in individuals with polymorphic VT as it associated with a prolonged QT

interval which is made worse with antiarrhythmic drugs.

Amiodarone should only be used after defibrillation/cardioversion and first line drugs such as epinephrine and vasopressin have failed to convert VT/VF.

Amiodarone

Route

Amiodarone can be administered by intravenous or intraosseous route.

Dosing

The maximum cumulative dose in a 24 hour period should not exceed 2.2 grams.

Within the VT/VF pulseless arrest algorithm, the dosing is as follows: 300mg IV/IO push → (if no conversion) 150 mg IV/IO push → (after conversion) Infusion #1 360 mg IV over 6 hours (1mg/min) → Infusion #2 540 mg IV over 18 hours (0.5mg/min)

For tachyarrhythmias other than life threatening, expert consultation should be considered before use.

For Tachycardia other than pulseless VT/VF, Amiodarone dosing is as follows: (see above note) 150 mg over 10 minutes → repeat as needed if VT recurs → maintenance infusion of 1mg/min for 6 hours

Amiodarone should only be diluted with D5W and given with an in-line filter.

Infusions exceeding 2 hours must be administered in glass or polyolefin bottles containing D5W.

Although lidocaine was removed from the 2010 Simplified Pulseless Arrest Diagram, it is

still considered a suitable alternative if amiodarone is ineffective in cardiac arrest from

VT/VF.

Lidocaine was removed in the AHA Simplified Pulseless Arrest Diagram to help reduce

emphasis on the use of medications and place more emphasis on high quality CPR and

early defibrillation.

Indications for ACLS In ACLS, Lidocaine is used intravenously for the treatment of ventricular arrhythmias.

(VT/VF)

It is also useful for the treatment of stable monomorphic VT with preserved ventricular

function and for stablepolymorphic VT with preserved left ventricular function, normal

QT interval, and correction of any electrolyte imbalances.

The overall benefits of lidocaine for the treatment arrhythmias in cardiac arrest has come

under scrutiny. It has been shown to have no short term or long term efficacy in cardiac

arrest.

Routine prophylactic use is contraindicated for acute myocardial infarction.

lidocaine

1. Liver dysfunction increases the risk of toxicity due to lidocaine being metabolized by

the liver.

2. Low protein increases the risk of toxicity because lidocaine is protein bound.

3. Acidosis can also increase the risk of toxicity since acidosis increase the potential of

lidocaine to dissociate from plasma proteins.

Dosing Cardiac Arrest from VT/VF:

Initial dose: 1 to 1.5 mg/kg IV/IO

For refractory VF may give additional 0.5 to 0.75 mg/kg IV push, repeat in 5 to 10

minutes; maximum 3 doses or total of 3mg/kg

Perfusing Arrhythmia:

For stable VT, wide-complex tachycardia of uncertain type and significant ectopy:

Doses Range from 0.5 to 0.75 mg/kg and up to 1 to 1.5mg/kg

Repeat 0.5 to 0.75 mg/kg every 5-10 minutes with maximum total dose of 3 mg/kg

Maintenance infusion:

1 to 4 mg/min (30-50 mcg/kg/min)

Discontinue a lidocaine infusion immediately if signs of toxicity develop.

When bradycardia is being treated in ACLS, if an underlying cause cannot be identified and corrected, medications are indicated.

There are three medications used in the bradycardia algorithm: atropine, epinephrine, and dopamine. Each drug and its use within the bradycardia algorithm is explained below.

Bradycardia

Atropine

Atropine is the first drug used to treat bradycardia in the bradycardia algorithm. It is

classified as an anticholinergic drug and increases firing of the SA Node by blocking the

action of the vagas nerve on the heart resulting in an increased heart rate.

Atropine should be used cautiously in the presence of myocardial ischemia and hypoxia

since it increases oxygen demand of heart and can worsen ischemia.

The dosing for Atropine is 0.5 mg IV every 3-5 minutes as needed, and the maximum total

dosage that can be give is 3 mg.

Atropine should be avoided in hypothermic bradycardia and it will not be effective for Mobitz

type II/Second Degree Block Type 2.

You may have read that Atropine is not effective for Mobitz II (2nd degree block type II) and Complete Heart Block (3rd degree block)

Epinephrine and Dopamine

Epinephrine and dopamine are second-line drugs for symptomatic bradycardia. They are

both used as infusions in the bradycardia algorithm if atropine is ineffective.

New 2010 ACLS guidelines state that if bradycardia is unresponsive to atropine, an equally

effective alternative to transcutaneous pacing is the use of an IV infusion of the beta-

adrenergic agonists (dopamine or epinephrine).

Dosing:

Begin the epinephrine infusion at 2 to 10 mcg/min and titrate to patient’s response.

The goal of therapy is to improve the patient’s clinical status rather than target an exact

heart rate.

Begin the dopamine infusion at 2 to 10 mcg/kg/min and titrate to the patient’s response.

Precautions

Prior to use of ACLS drugs in the treatment of symptomatic bradycardia, contributing factors

of the bradycardia should be explored then ruled out or corrected.

Adenosine should be used within the tachycardia algorithm when vagal maneuvers fail to terminate stable narrow-complex SVT.

Adenosine is the primary drug used in the treatment of stable narrow-complex SVT (supraventricular Tachycardia). It can now also be used for regular monomorphic wide-complex tachycardia. When given as a rapid IV bolus, adenosine slows cardiac conduction particularly effecting conduction through the AV node. The rapid bolus of adenosine also interrupts reentry (SVT causing) pathways through the AV node and restores sinus rhythm in patients with SVT.

When injected into the body, adenosine is rapidly absorbed by red blood cells and blood vessel endothelial cells and metabolized for natural uses throughout the body. In light of this adenosine should be administered by RAPID intravenous bolus so that a significant bolus of adenosine reaches the heart before it is metabolized.

A change from the 2010 guidelines now has adenosine given up to two times rather than three.

Dosing

The first dose of adenosine should be 6 mg administered rapidly over 1-3 seconds followed by a 20 ml NS bolus. If the patient’s rhythm does not convert out of SVT within 1 to 2 minutes, a second 12 mg dose may be given in similar fashion. All efforts should be made to administer adenosine as quickly as possible.

Precautions

Some side effects of adenosine administration incude flushing, chest pain/tightness, brief asystole or bradycardia.

Make sure that adenosine is not used for irregular, polymorphic wide-complex tachycardia and unstable VT. Use in these cases may cause clinical deterioration.

Drug Name Adult Dose Pediatric Dose Indications Frequency Effects

Epinephrine 1 mg IVOR2-5 mg IV via ETT

0.01 mg/kg IV or 10OR0.1 mg/kg via ETT

Any pulseless rhythms

Every 3-5 min Increases perfusion to myocardium and to brain by increasing peripheral vascular resistance

Vasopressin 40 units IV Not indicated VF, pulseless VT Single dose, may be followed at 10 min by epinephrine

Increases peripheral vascular resistance

Amiodarone For VF or pulseless VT: 300 mg IV push

For VF or pulseless VT: 5 mg/kg IV push

VF, pulseless VT, VT with a pulse, SVT

May use second dose of 150 mg for recurrent VF/VT. In children may be repeated in 5 mg/kg doses to a total of 15 mg/kg

Predominately class III antiarrhythmic, but has sodium, potassium channel, and α and β receptor blockade

Lidocaine 1.0-1.5 mg/kg IV push

Same VF, pulseless VT, VT with a pulse

Second and subsequent doses of 0.75 mg/kg every 5 min to a total dose of 3 mg/kg

Class IB antiarrhythmic; suppresses ventricular automatically and electrical conduction

Magnesium 1-2 g IV slow push 25-50 mg/kg IV slow push

Torsade de pointes, known hypomagnesemia

Single dose Can cause cutaneous flush, apnea, and hyporeflexia, if given too quickly

ETT, endotracheat tube; IO, intraosseoulsy; IV, intravenously; SVT, supraventricular tachycardia; VF, ventricular fibrillation; VT, ventricular tachycardia.*Agents are listed from most effective (and most commonly used) to least.

Procainamide 17 mg/kg IV slow bolus at maximum rate of 50 mg/min

15 mg/kg IV load; 3-6 mg/kg over 5 min, not to exceed 100 mg/dose

VT with a pulse Continue infusion (4 mg/min) until QRS widening >50%, dysrhythmia terminated, onset of hypotension; or 17 mg/kg infused

Decreases myocardial excitability and conduction velocity

Atropine Perfusing patients: 0.5 mg IV push q 5 min, to maximum of 3 mgPulseless patients: 1.0 mg IV push q 5 min, to maximum of 3 mg

0.02 mg/kg: minimum dose of 0.1 mg

Bradycardia, asystole

May be repeated once up to maximum dose of 3 mg

Parasympatholytic, eliminates vagal tone

Adenosine 6 mg rapid IV push through proximal peripheral line; central line dose is one-half

0.1 mg/kg rapid IV push; maximum dose, 6 mg

SVT If needed, second dose of 12 mg (pediatric, double initial dose up to 12 mg); third dose of 12-18 mg

Endogenous nucleoside causing brief asystole allowing dominant pacemaker to resume function

Diltiazem 0.25 mg/kg to a maximum dose of 20 mg IV push over 2 min

Same SVT Second dose of 0.35 mg/kg, maximum dose of 25 mg, at 15 min; after conversion, start diltiazem drip at 5-15 mg/h

Calcium channel blocker


Esmolol 500 ug/kg bolus over 1 min

100-500 ug/kg bolus over 1 min

SVT May give another bolus if desired effect is not achieved; start drip 50 ug/kg/min

β-Blocker (short acting)

Atenolol 5 mg IV over 5 min Not indicated SVT, myocardial infarction

Repeat in 10 min, then give 50-mg oral load

β-Blocker (β1 selective)

Metoprolol 5 mg IV push Not indicated SVT, myocardial infarction

Repeat twice at 5-min intervals, then give 50-mg oral load

β-Blocker (β1 selective)

Dopamine 2-20 ug/kg/min Same Hypotension Low doses are predominantly β; higher doses become predominantly α

Inotropic agent/vasopressor (combined α- and β-agonists)


Dobutamine 2-20 ug/kg/min Same Hypotension Titrate to effect Inotropic agent (β-agonist)

Norepinephrine

Start at 8-12 ug/min, then titrate to 2-4 ug/min for maintenance; maximum dose of 30 ug/min if hypotension unresponsive to lower doses

0.05-2 ug/kg/min Hypotension Titrate to effect Vasopressor (predominately an α-agonist)

Phenylephrine 100-500 ug bolus IV

0.1-0.5 ug/kg/min Hypotension Every 5 min until desired effect, then continuous infusion of 40-180 ug/min

Vasopressor (pure α-agonist)


Date post:	16-May-2015
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