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What's
all this talk about amiodarone (Cordarone)
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An
antiarrhythmic (Class III) that prolongs duration of action potential
and effective refractory period, also provided noncompetitive a- and b-
adrenergic inhibition. It decreases AV conduction velocity and sinus
node function.
It is indicated for unstable VT, VF and SVT refractory to other
therapyand is said to be effective first line medication for VT/VF in
cardiac arrest.
Amiodarone is a new intervention based on its successful use in several
clinical trials. Some say it increased to-hospital survivability, but
others say survivability upon release from the hospital is no better
than lidocaine, at a fraction of the cost. It must be mixed and then
drawn up slowly to avoid 'bubbles'. |
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Asystole
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Primary
ABCD Survey (1)
Focus:
basic CPR and defibrillation
Check
responsiveness
Activate EMS
Call for defibrillator
A irway: open the airway
B reathing: provide positive-pressure
ventilations
C irculation: give chest compressions
C onfirm true asystole
D efibrillation: assess for VF/pulseless
VT; shock if indicated
Rapid scene survey: any evidence
personnel should not attempt
resuscitation?
Secondary
ABCD Survey (2,3)
Focus:
more advanced assessments and treatments
A
irway: place airway device as soon as possible
B reathing: confirm airway device
placement by exam PLUS confirmation device
B reathing: secure airway device;
purpose-made tube holders preferred
B reathing: confirm effective
oxygenation and ventilation
C irculation: establish IV access
C irculation: identify rhythm ->
monitor
C irculation: administer drugs
appropriate for rhythm and condition
D ifferential Diagnosis: search for and
treat idenfitifed reversible causes
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Transcutaneous
pacing (4)
if considered, perform immediately
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Epinephrine
1 mg IV push, repeat every 3 to 5 minutes (5)
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Atropine
1 mg IV push, repeat every 3 to 5 minutes as needed,
tp
to a total dose of 0.04 mg/kg. (6)
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Asystole
persists-
withhold or cease resuscitative efforts? (7,8,9)
consider quality of resuscitation?
atypical clinical features present?
support for cease-efforts protocols in place?
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| (1)
Scene Survey: DNR patient?
If Yes, do not start/attempt resuscitation. Any objective
indicators of DNR status? Bracelets? Anklet? Written
documentation? Family statements? If Yes: do not start/attempt
resuscitation. Any clinical
indicators that resuscitation attempts are not indicated?
(e.g., signs of death? If Yes: do not start/attempt
resuscitation).
(2)
Confirm true asystole.
Check lead and cable connections. Monitor power on?
Monitor gain up? Verify asystole in another lead.
(3)
Sodium Bicarbonate 1 mEq/kg:
indications for use include overdose of tricyclic
antidepressants; to alkalinize urine in overdoses;
patients with tracheal intubation plus long arrest
intervals; on return of spontaneous circulation if there
is a long arrest interval. Ineffective or harmful in
hypercarbic acidosis.
(4) Transcutaneous Pacing: to
be effective, must be performed early, combined with drug
therapy. Evidence does not support routine use of TCP for asystole.
(5) Epinephrine: recommended
dose is 1 mg IV push every 3-5 minutes (class
indeterminate). If this approach fails, higher doses of
epinephrine (up to 0.2 mg/kg) may be used but are not
recommended.
There is a lack of evidence for vasopressin use in
victims of PEA or asystole.
(6) Atropine: use shorter
dosing interval (every 3 to 5 minutes) in cardiac arrest.
(7) Review the quality of the
resuscitation attempt: was there an adequate
trial of BLS? of ACLS? Has the team done the following:
achieved tracheal intubation, performed effective
ventilation, shocked VF if present, obtained IV access,
given epinephrine IV, given atropine IV, ruled out or
corrected reversible causes, and continuously documented
asystole >5 to 10 minutes after all of the above have
been accomplished?
(8) Reviewed for atypical clinical
features? Not a victim of drowning or
hypothermia? No reversible therapeutic or illicit drug
overdose? "Yes" to the questions in Notes 7
and 8 means the resuscitation team complies with
recommended criteria to terminate resuscitative efforts
where the patient lies (IIa). If the response
team and patient meet the above criteria, then withhold
urgent field-to-hospital transport with continuing CPR=Class
III (harmful; no benefit).
(9) Withholding or stopping
resuscitative efforts out-of-hospital: If
criteria in 7 and 8 are fulfilled: field personnel, in
jurisdictions where authorized, should start protocols to
cease resuscitative efforts or to pronounce death outside
the hospital (Class IIa). In most US settings, the
medical control official must give direct voice-to-voice
or on-scene authorization. Advanced planning for these
protocols must occur. The planning should include
specific directions for: leaving the body at scene, death
certification, transfer to funeral service, on-scene
family advocate, and religious or non-denominational
counseling.
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Bradycardia
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Slow
-absolute
bradycardia is a rate < 60 bpm
or
Relatively slow- (rate less than
expected relative to underlying condition or cause)
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Primary
ABCD Survey
Assess ABC's
Secure
airway non-invasively
Ensure monitor/defibrillator is available
Secondary
ABCD Survey
Assess
secondary ABC's (invasive airway management needed?)
Oxygen-IV
access-monitor-fluids
Vital signs, pulse oximeter, monitor BP
Obtain and review 12-lead EKG
Obtain and review portable chest x-ray
Problem-focused history
Problem-focused physical examination
Consider causes (differential diagnoses)
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Serious
signs or symptoms?
(1,2)
(due to bradycardia)
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YES (Serious
Signs or Symptoms): Intervention
Sequence:
(3,4,5)
* Atropine 0.5
to 1.0 mg
*
Transcutaneous pacing if available
* Dopamine 5 to 20 mcg/kg per minute
* Epinephrine 2 to 10 mcg per minute
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NO
Serious Signs or Symptoms: (6)
Type II second-degree
AV block or Third-degree AV block?
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YES (Type
II 2nd-deg AV or 3rd-deg AV Block):
(7)
Prepare for
transvenous pacer
If
symptoms develop, use transcutaneous pacemaker until transvenous pacer placed
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NO (Type II 2nd-deg AV
block or 3rd-deg AV Block): Observe
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(1) If the patient has serious signs or
symptoms, make sure they are related to the slow rate.
(2)
Clinical manifestations include
symptoms (chest pain, shortness of breath, decreased
level of consciousness) and signs (hypotension, shock,
pulmonary congestion, congestive heart failure).
(3)
If the patient is
symptomatic, do not delay transcutaneous pacing while
awaiting IV access or for atropine to take effect.
(4) Denervated transplanted hearts
will not respond to atropine. Go at once to pacing,
catecholamine infusion, or both.
(5) Atropine should be given in repeat
doses every 3-5 minutes up to a total of 0.03 to 0.04 mg/kg.
Use shorter dosing interval (3 minutes) in severe
clinical rhythms.)
(6)
Never treat the combination of
third-degree heart block and ventricular escape beats
with lidocaine (or any agent that suppresses ventricular
escape rhythms).
(7) Verify patient tolerance and
mechanical capture. Use analgesia and sedation as needed.
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Pulseless Electrical Activity (PEA)
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rhythm on monitor with no pulse
Primary
ABCD Survey
Focus:
basic CPR and defibrillation
Check
responsiveness
Activate EMS
Call for defibrillator
A Airway: open the airway
B Breathing: provide positive-pressure
ventilations
C Circulation: give chest compressions
D Defibrillation: assess for VF/pulseless
VT; shock if indicated
Secondary
ABCD Survey
Focus:
more advanced assessments and treatments
A
irway: place airway device as soon as possible
B reathing: confirm airway device
placement by exam PLUS confirmation device
B reathing: secure airway device;
purpose-made tube holders preferred
B reathing: confirm effective
oxygenation and ventilation
C Circulation: establish IV access
C irculation: identify rhythm ->
monitor
C irculation: administer drugs
appropriate for rhythm and condition
C irculation:
assess for occult blood flow ("pseudo-EMT")
D ifferential Diagnosis: search for and
treat identified reversible causes
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Review
for most frequent causes (1)
Hypovolemia, Hypoxia, Hydrogen
ion (acidosis), Hyper-hypokalemia, Hypothermia,
Tablets (drug OD), Tamponade
(cardiac), Tension pneumothorax, Thrombosis
(coronary), Thrombosis (pulmonary
embolism).
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Epinephrine
1 mg IV push, repeat every 3 to 5 minutes (2)
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Atropine
1 mg IV (if PEA rate is slow),
repeat every 3 to 5 minutes as needed, to a total dose of
0.04 mg/kg. (3)
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(1)
Sodium
Bicarbonate 1 mEq/kg: class I (acceptable,
supported by definitive evidence) if patient has known,
preexisting hyperkalemia.
Class IIa (acceptable, good evidence
supports) if known, preexisting
bicarbonate-responsive
acidosis; in tricyclic antidepressant overdose;
to
alkalinize urine in aspirin or other drug overdoses.
Class IIb (acceptable, only fair
evidence provides support) in intubated and ventilated
patients with long arrest interval; on return of
circulation, after long arrest interval.
Class III (may be harmful) in
hypercarbic acidosis.
(2) Epinephrine:
recommended dose is 1 mg IV push every 3-5 minutes (class
indeterminate).
If this approach fails, higher doses
of epinephrine (up to 0.2 mg/kg) may be used but are not
recommended.
There is a lack of evidence for vasopressin use in
victims of PEA or asystole.
(3)
Atropine:
shorter dose interval (every 3-5 mins) is possibly
helpful in cardiac arrest.
Atropine 1 mg IV if electrical activity
is slow (absolute bradycardia=rate <60 bpm)
or relatively slow (relative bradycardia=rate less than
expected relative to the underlying condition).
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V-FIB/PULSELESS V-TACH
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Primary
ABCD Survey (1)
Focus:
basic CPR and defibrillation
Check
responsiveness
Activate EMS
Call for defibrillator
A irway: open the airway
B reathing: provide positive-pressure
ventilations
C irculation: give chest compressions
D efibrillation: assess for and shock
VF/pulseless VT, up to 3 times (200 J, 200-300 J, 360 J,
or equivalent biphasic) if necessary
Rhythm after
first 3 shocks?
Persistent
or recurrent VF/VT:
Secondary ABCD Survey (2)
Focus:
more advanced assessments and treatments
A
irway: place airway device as soon as possible
B reathing: confirm airway device
placement by exam PLUS confirmation device (2A)
B reathing: secure airway device;
purpose-made tube holders preferred (2B)
B reathing: confirm effective
oxygenation and ventilation (2C)
C irculation: establish IV access
C irculation: identify rhythm ->
monitor
C irculation: administer drugs
appropriate for rhythm and condition
D ifferential Diagnosis: search for and
treat identified reversible causes
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Epinephrine
1 mg IV push (repeat every 3 to 5 minutes) (3A)
OR
Vasopressin 40 U IV, single dose,
1 time only (see below) (3B)
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Resume
attempts to defibrillate
1 x 360 J (or equivalent biphasic energy) within 30 to 60
seconds
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Consider
antiarrhythmics:
(4)
amiodarone (IIb), lidocaine
(indeterminate), magnesium (IIb if
hypomagnesemic state), procainamide (IIb
for intermittent/recurrent VF/VT).
Consider buffers. (4B)
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Resume
attempts to defibrillate. (5)
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(1)
Defibrillatory shock waveforms: use monophasic
shocks at listed energy levels (200 J, 200-300
J, 360 J) or biphasic shocks at energy
levels documented to be clinically equivalent (or
superior) to the monophasic shocks. [NOTE: Circulation
I-150 lists the above monophasic shocks at 300 J, 300-360
J, and 360 J. It is believed this is in error as the
algorithm lists the 200, 200-300, then 360 sequence.]
(2A) Confirm
tube placement with primary physical examination
criteria plus secondary confirmation device (end-tidal
CO2, end-diastolic diameter) (Class IIa)
(2B) Secure
tracheal tube to prevent dislodgement,
especially in patients at risk for movement, use purpose-made
(commercially available) tracheal tube holders, which are
superior to tie-and-tape methods (Class IIb). Consider
cervical collar and backboard for transport (Class
Indeterminate). Consider continuous, quantitative end-tidal
CO2 monitor (Class IIa).
(2C) Confirm
oxygenation and ventilation with end-tidal CO2
monitor and oxygen saturation monitor.
(3A) Epinephrine
(Class Indeterminate) 1 mg IV push every 3-5 minutes. If
this fails, higher doses of epinephrine (up to 0.2 mg/kg)
are acceptable but not recommended (there is
growing evidence that it may be harmful).
(3B) Vasopressin
is recommended only for VF/VT; there is no
evidence to support its use in asystole or PEA. There is
no evidence about the best approach if there is no
response after a single bolus of vasopressin. The
following Class Indeterminate action is acceptable, but
only on the basis of rational conjecture. If there is no
response 5-10 minutes after a single IV dose of
vasopressin, it is acceptable to resume
epinephrine 1 mg IV push every 3-5 minutes.
(4) Antiarrhythmics are
indeterminate or Class IIb: acceptable; only fair
evidence supports possible benefit of antiarrhythmics for
shock-refractory VF/VT.
Amiodarone
(Class IIb): 300 mg rapid IV push (cardiac arrest dose)
diluted in 20-30 mL of normal saline or D5W. If VF/pulseless
VT recurs, consider second dose of 150 mg. Maximum
cumulative dose is 2.2 g over 24 hours.
Lidocaine (Class
Indeterminate): 1.0-1.5 mg/kg IV push. Consider repeat in
3 to 5 minutes to a maximum cumulative dose of 3 mg/kg. A
single dose of 1.5 mg/kg in cardiac arrest is acceptable.
Magnesium Sulfate:
1 to 2 g IV in polymorphic VT (torsades de pointes) and
suspected hypomagnesemic state.
Procainamide: 30
mg/min in refractory VF (maximum total dose: 17 mg/kg) is
acceptable but not recommended because prolonged
administration time is unsuitable for cardiac arrest.
(4B) Sodium Bicarbonate: 1 mEq/kg
IV is indicated for several conditions known to provoke
sudden cardiac arrest.
(5) Resume defibrillation attempts:
use 360 J (or equivalent biphasic energy setting) shocks
after each medication or after each minute of CPR.
Acceptable patterns: CPR-drug-shock (repeat) or CPR-drug-shock-shock-shock
(repeat).
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American Heart Association ACLS guidelines
August 2000, Supplement 1 of Circulation
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