Present : PGY 王 淳 峻 Supervisor: F1 王 德 皓

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1 Present : PGY 王 淳 峻 Supervisor: F1 王 德 皓 Interventions to prevent cardiac arrest + Airway management + Ventilation support + Treatment of bradyarrhythmias & Tachyarrhythmias Treat cardiac arrest + Immediate recognition and activation of emergency response + Early CPR + Rapid defibrillation to further increase the likelyhood of ROSC with drug therapy + Advanced airway management and physiologic monitoring Improve outcomes of patients who achieve ROSC + Integrated post cardiac arrest care 8.1: Adjuncts for airway control and ventilation 8.2: Management of Cardiac arrest 8.3: Management of Symptomatic Bradycardia and Tachycardia + Continuous quantitative waveform capnography is recommended for confirmation and monitoring of endotracheal tube placement + Cardiac arrest algorithms are simplified and redesigned to emphasize the importance of high quality CPR : 1. chest compressions of adequate rate and depth 2. Complete chest recoil after each compression 3. minimizing interruptions in chest compressions 4. Avoiding excessive ventilation + Atropine is no longer recommended in the management of PEA/asystole + Emphasis on physiologic monitoring to optimize CPR quality and detect ROSC + Chronotropic drug infusions are recommended as an alternative to pacing in symptomatic and unstable bradycardia. + Adenosine is recommended as a safe and potentially effective therapy in the initial management of stable undifferentiated regular monomorphic wide complex tachycardia. + When treating VF/pulseless VT, do CPR first. + A brief chest compression can provide oxygen and energy substrate to the hypoxic myocardium, thus able to increase the likelihood of successful shock delivery. After shock, resume chest compression immediately. + When VF/pulseless VT persists after 1 shock then can consider drug therapies. + Think PEA Pitressin (vasopressin) Epinephrine Amiodarone improve the rate of ROSC with refractory VF/pulseless VT. Follow the protocol

2 + Vasopressor can be given as soon as feasible. + IMPORTANT: evidence have suggested that the routine use of atropine during PEA or asytole have little therapeutic benefits. Therefore, atropine has been removed from algorithm. 5H + 1) Hypovolemia 1) Tensiop neumothorax + 2) Hypoxia 2) Tamponade, cardiac + 3) Hypo/hyper K+ 3) Toxins + 4) Hypothermia 4) Thrombosis, pulmonary + 5) Hydrogen ion 5) Thrombosis, coronary 5T Mechanical parameter + Rate, depth of compression and rate of ventilation Physiologic parameter + ECG & Pulse check are the only physiologic parameter + Animal & human studies indicate that monitoring of Petco2, coronary perfusion pressure (CPP), and central venous oxygen saturation (Scvo2) provides valuable information. + An abrupt increase in any of these parameters is a sensitive indicator of ROSC that can be monitored without interrupting chest compression. (Class IIb, LOE C) Pulse + No more than 10s End Tidal CO2 (Petco2) + concentration of CO2 in exhaled air at the end of expiration + Noraml range: mmhg + Petco2 may be altered by NaHCO3 therapy (increase) and Vasopressin therapy (decrease) + Low Petco2 (<10mmHg) during CPR in intubated patients indicates that cardiac output is inadequate to achieve ROSC. + Abrupt increase in Petco2 during CPR is an indicator of ROSC. (Class IIa) + Use quatitatve waveform capnography in intubated patients to monitor CPR quality, optimize chest compression, and detect ROSC. (Class IIb)

3 Timing of IV/IO access Peripheral IV drug delivery Central IV drug delivery + The appropiately trained provider may consider placement of a central line (internal jugular or subclavian) during cardiac arrest, unless there are contraindications. (Class IIb) + Advantage: 1. peak drug concentration are higher and drug circulation times shorter compared with peripheral IV catheter. 2. can monitor Scvo2 and estimate CPP during CPR + Disadvantage: 1. can interrupt CPR 2. relative contraindication for fibrinolytic therapy in patients with ACS Endotracheal drug delivery + Drugs that can be absorbed via the trachea: lidocaine, epinephrine, atropine, naloxone, and vasopressin. (No amiodarone) + If IV or IO access cannot be established, epinephrine, vasopressin and lidocaine may be administered by endotracheal route during cardiac arrest. (Class IIb) + The optimal endotracheal dose of most drugs is unknown, but times IV dose could be given. + Deliver at least 100 compression per minute continuously without pauses for ventilation. + Delivering ventilations should give 1 breath every 6 8 seconds (8 10 breaths per minutes) + Avoid delivering an excessive number of ventilations. + There is evidence, at any stage during management of Vf, pulseless VT, PEA, or asystole increased rate of ROSC. + No difference in outcomes with vasopressin (40 U IV) versus epinephrine (1 mg) as a first line vasopressor in cardiac arrest. Epinephrine + 1mg dose of IV/IO epinephrine every 3 5 minutes during adult cardiac arresr (Class II b) Vasopressin + Because the effects of vasopressin have not been shown to differ frome those of epinephrine in cardiac arrest, 1 dose of vasopressin 40 units IV/IO may replace either the first or second dose of epinephrine. (Class II b) Amiodarone + May be considered for Vf or pulseless VT unresponsive to CPR, defibrillation, and a vasopressor therapy. (Class II b) + An initial dose of 300mg IV/IO can be followed by 1 dose of 150 mg IV/IO. Lidocaine + Lidocaine may be considered if amiodarone is not available. (Class II b) + The initial dose is mg/kg IV. + If VF/pulseless VT persisted, additional doses of mg/kg IV push may be administered at 5 10 minute intervals to a maximum dose of 3 mg/kg. Magnesium Sulfate + IV Magnesium sulfate can facilitate termination of torsades de pointes (irregular/polymorphic VT associated with prolonged QT interval). + Optimal dosing regimen has not been established. + When VF/pulseless VT cardiac arrest is associated with torsades de pointes, IV/IO bolus of magnesium sulfate at a dose of 1 2 g diluted in 10ml D5W may be administered. (Class II b) + Routine administration of magnesium sulfate is NOT recommended (Class III) unless torsades de pointes is present. Atropine + Decrease HR & AV node conduction + Available evidence suggests that routine use of Atropine during PEA or asystole is unlikely to have a therapeutic benefit. (Class II b)for this reason, atropine has been removed from the cardiac arrest algorithm. Sodium Bicarbonate + Tissue acidosis and resulting acidemia during cardiac arrest and resuscitation are dynamic process resulting from no blood flow during arrest and low blood flow during CPR. + Mainstays of restoring acid base balance are restoration of oxygen content with appropriate ventilation with oxygen, support of some tissue perfusion and some cardiac output with high quality chest compression.

4 Calcium + Routine administration of calcium for cardiac arrest is not recommended. (Class III) Fibrinolysis + For use during cardiac arrest to treat both coronary thrombosis (ACS) with presumably complete occlusion of a proximal coronary artery and major life threatening pulmonary embolism. + Some studies showed an increased risk of intracranial bleeding associated with the routine use of fibrinolytics during cardiac arrest. + Not be routinely used in cardiac arrest. (Class III) + When pulmonary embolism is presumed or known to be the cause of cardiac arrest, empirical fibrinolytic therapy can be considered. (Class II a) IV fluid + If cardiac arrest is associated with extreme volume losses, hypovolemic arrest should be suspected and intravascular volume should be promptly restored. Pacing + Electric pacing is generally not effective in cardiac arrest. + Not recommended for routine use. (Class III) Precordial Thump + When administered for VF/VT or PEA arrest it was ineffective but resulted in no apparent harm. + May be considered for termination of witnessed monitored unstable ventricular tachyarrhythmia when a defibrillator is not immediately ready for use. (Class II b) but should not delay CPR and shock delivery. + Emphasize the importance of clinical evaluation Key principles of arrhythmia recognition and management in adults: 1. Bradycardia with S/S: initial treatment is Atropine (Class II a) if unreponsive, then try IV infusion of B adrenergic agonists with rate accelerting effects (dopamine, epinephrine)or transcutaneous pacing (TCP). (Class II a) 2. Tachycardia with unstable and S/S related to a suspected arrhythmia : Immediate cardioversion (Class I) 3. Regular narrow complex tachycardia with unstable S/S : a trial of adenosine before cardioversion is reasonable to consider (Class II b) Evaluation: + Generally Bradycardia cause symptoms at the rate of less than 50 bpm + Hypoxemia is a common cause of bradycardia + Initial evaluation should focus on signs of: 1. increase work of breathing (eg. Tachypnea) 2. Oxyhemoglobin saturation (determined by pulse oximetry) Therapy Atropine + Atropine remains the first line drug for acute symptomatic bradycardia (Class II a) + Recommended Atropine dose for bradycardia is 0.5 mg IV every 3 5 mins to a maximun total dose of 3 mg. + Use atropine cautiously in the presence of Acute coronary iscehmia or MI, because increase HR may worsen ischemia or increase infarction size. + Atropine does not work in patients who have undergone cardiac transplanation, because it lacks vagal innervation. Therapy Pacing + Initiate TCP in unstable patients who do not respond to atropine. (Class IIa) + Immediate pacing might be considered in unstable patients with high degree AV block when IV access is not available. (Class IIb) + If the patient does not respond to drugs or TCP, transvenous pacing is probably indicated. (Class IIa) Alternative Drugs to consider + Dopamine or epinephrone or isoproterenol infusion may be used for patients with symptomatic bradycardia, particularly if associated with hypotension, in whom atropine may be inappropriate or after atropine fails. (Class II b) + Dopamine infusion at 2 10 mcg/kg/min and titrate to patient response. + Epinephrine infusion at 2 10 mcg/min and titrate to patient resposnse. + Isoproterenol infusion at 2 10mcg/min and titrated according to HR & rhythm.

5 Narrow QRS complex (SVT) tachycardias (QRS 0.12s) + Sinus tachycardia + Atrial fibrillation + Atrial flutter + AV nodal reentry + Accessory pathway mediated tachycardia + Atrial tachycardia (including automatic and reentry forms) + Multifocal atrial tachycardia (MAT) + Junctional tachycardia (rare in adults) Wide QRS complex tachycardias (QRS 0.12 second) + Ventricular tachycardia (VT) and ventricular fibrillation (VF) + SVT with aberrancy + Pre excited tachycardias (Wolff Parkinson White [WPW] syndrome) + Ventricular paced rhythms Synchronized cardioversion and unsynchronized shocks + Synchronized cardioversion is recommended to treat unstable SVT, unstable Af, unstable Atrial flutter, and unstable monomorhpic (regular) VT. + If cardioversion is needed and it is impossible to synchronize a shock, use high energy unsynchronized shock (defibrillation doses). Waveform and Energy + The recommended initial biphasic energy dose for cardioversion of Af is J (Class IIa) + Cardioversion of atrial flutter and other SVTs generally requires less energy; an initial energy of J + Monomorphic VT (regular form and rate) with a pulse responds well to monophasic or biphasic waveform cardioversion (synchronized) shocks at initial energies of 100 J. + If a patient has polymorphic VT, treat therhythm as VF and deliver high energy unsynchronized shocks. Sinus Tachycardia treat underlying diseases Supraventricular Tachycardia (Reentry SVT) + Supraventricular origin: narrow QRS complex (<0.12s) or broad QRS complex and preexisting bundle branch block. Vagal maneuvers + Vagal maneuvers and adenosine are the preferred initial therapeutic choices for the termination of stable PSVT. Adenosine + If PSVT does not respond to vagal maneuvers, give 6mg of IV adenosine as a rapid IV push through a large vein followed by a 20ml saline flush. (Class I) + If the rhythm does not convert within 1 to 2 minutes, give a 12mg rapid IV push. Calcium channel blockers and B blocker + Use longer acting AV nodal blocking agents such as nondihydropyridine Ca channel blockers (Verapamil and diltiazem) or B Blockers if adenosine and vagal maneuver fails. (Class II a) + For Verapamil, give 2.5mg to 5mg IV bolus over 2 mins.(3mins in older patients) + Verapamil should be given only to patients with narrow complex reentry SVT or arrhythmias known with certainty to be supraventricular origin. Calcium channel blockers and B blocker (conts) + For diltiazem, give a dose of 15mg to 20mg (0.25mg/kg) IV over 2 minutes.

6 + QRS 0.12 seconds + VT or VF + SVT with aberrancy + Pre excited tachycardias (associated with or mediated by an accessory pathway) + Ventricular paced rhythms

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