ACLS: Pulseless Arrest

Transcription

1 ACLS: Pulseless Arrest Suprat Saely, PharmD, BCPS Clinical Pharmacist Specialist, Emergency Medicine December 2, 2013 REPS EC SAG 4 Objectives Review the current ACLS pulseless algorithms Discuss the medications commonly utilized for ACLS pulseless rhythms Describe therapeutic hypothermia in post cardiac arrest care Cardiac Arrest Statistics (2013) Out-of-Hospital In-Hospital 359,400 Incidence 209, % Survival Rate 23.1% 40.1% Bystander CPR n/a Circulation 2013;127:e6-e245 1

2 Chain of Survival Recognition CPR Defibrillation ACLS Post-cardiac arrest care ACLS Cardiac Arrest: Pulseless Rhythms Shockable Non-Shockable Ventricular Fibrillation Asystole Ventricular Tachycardia PEA 2

3 Treatment Algorithms VF/VT Asystole/PEA Defibrillate (360 J for monophasic or J for biphasic) Identify most common causes (Hs & Ts) Epinephrine 1mg Q3-5min Vasopressin 40units, one dose only Consider antiarrhythmics Amiodarone Lidocaine Magnesium (torsades) Others (procainamide) C P R Identify most common causes (Hs & Ts) Epinephrine 1mg Q3-5min Vasopressin 40units, one dose only Defibrillation Strategies in VF/VT Monophasic (360 J) Biphasic ( J) Use max dose when unsure Subsequent shock is at least equivalent or higher energy levels Reversible Causes: The H s & T s Hypoxia Hypovolemia Hydrogen ion (acidosis) Hypo-/hyperkalemia Hypothermia Tension pneumothorax Tamponade (cardiac) Toxins Thrombosis, coronary Thrombosis, pulmonary 3

4 ACLS Drug Therapy ROSC hospital admission Not associated with improved long-term survival or good neurologic outcome 851 OHCA pts IV ACLS drugs (n=418) vs. No IV ACLS drugs (n= 433) Hospital admission with ROSC: 32% (drugs) vs. 21% (no drugs); p<0.05 Survival to hospital discharge: 10.5% (drugs) vs. 9.2% (no drugs); p=ns Survival with favorable neurologic outcome: 9.8% (drugs) vs. 8.1% (no drugs); p=ns ; JAMA. 2009;302(20): Drug Administration Intravenous Peripheral 20 ml NS Central Intraosseous Same dose as IV IO kits available EZ-IO Endotracheal x IV dose Drugs Naloxone Atropine Vasopressin Epinephrine Lidocaine Medications in Pulseless Arrest Epinephrine α- and β-receptor agonist coronary perfusion pressure cerebral perfusion pressure myocardial oxygen demand ROSC, but no survival benefit 4

5 Medications in Pulseless Arrests Epinephrine 1 mg Q 3 5 min IV / IO 1:10,000 conc. (Abboject) ET (2-2.5 mg) 1:1,000 conc. diluted to 10 ml SW/NS or use 1:10,000 conc (x2) Higher dose generally not recommended, but may be indicated for specific causes Medications in Pulseless Arrests Vasopressin Non-adrenergic peripheral vasoconstrictor coronary perfusion pressure vital organ blood flow Does not myocardial oxygen demand Medications in Pulseless Arrests Vasopressin Wenzel, et al 1 Gueugniaud, et al 2 1,186 OHCA patients Vasopressin 40 units (may repeat) vs. epinephrine 1 mg No difference in ROSC, hospital admission or discharge hospital admission and discharge in asystole arrests 1,442 OHCA patients Vasopressin 40 units (may repeat) + epi 1mg vs. placebo + epi 1mg No difference in ROSC, hospital admission or discharge or neurologic recovery 1. NEJM 2004;350: NEJM 2008;359:

6 Medications in Pulseless Arrests Vasopressin 40 units Replace 1 st or 2 nd dose of epinephrine May be given undiluted IV/IO/ET Half-life = minutes Antiarrhythmics in VF/VT Amiodarone Preferred antiarrhythmic agent Considered for VF/VT unresponsive to shock delivery Inhibits ion influx through Na+, K+, Ca+ channels Has α- and - blocking activities Antiarrhythmics in VF/VT Amiodarone ARREST Trial OHCA patients with VF Amiodarone 300 mg vs. placebo (single dose only) survival to hospital admission No difference in hospital discharge ALIVE Trial OHCA patients with shockresistant VF Amiodarone 5mg/kg vs. Lidocaine 1.5mg/kg (repeat at ½ initial dose allowed) survival to hospital admission in amiodarone group No difference in hospital discharge 1.NEJM. 1999;341(12): NEJM.2002;346(12):

7 Antiarrhythmics in VF/VT Amiodarone 300 mg bolus Dilute in ml of D5W/NS IV/IO push (Not via ET route) May repeat with 150 mg May cause hypotension Antiarrhythmics in VF/VT Lidocaine mg/kg bolus (may repeat mg/kg); max dose 3 mg/kg Inhibits ion influx through Na+ channels Inadequate evidence for use in refractory VT/VF May be considered if amiodarone is unavailable Medications in VF/VT Magnesium 1-2 gm for Torsades Dilute in 10 ml D5W/NS given bolus Terminates torsades de pointes Routine administration in cardiac arrest is not recommended 7

8 Not Recommended Routinely in Pulseless Arrest Atropine Conflicting evidence on the benefit, but unlikely to be beneficial No longer recommended for PEA/Asystole arrests Sodium bicarbonate Majority of studies showed no benefit or worse outcome Only in special circumstances Calcium No beneficial effects on survival Only in special circumstances Fibrinolysis Only in suspected acute MI and pulmonary embolism Postresuscitative Care integrated post-cardiac arrest care Therapeutic Hypothermia Controlled induced hypothermia (32 C- 34 C) for hours Comatose adult patients with ROSC after Out-of-hospital VF cardiac arrest (Class I) In-hospital cardiac arrest of any initial rhythm (Class IIb) Out-of-hospital cardiac arrest with PEA/Asystole (Class IIb) Circulation 2010;122:S768-S1002 8

9 Therapeutic Hypothermia HACA Group comatose post cardiac arrest patients (VF/ nonperfusing VT) with ROSC Hypothermia vs. normothermia favorable neurologic outcome in hypothermia group Decreased 6-month mortality Australian Study 2 77 comatose post cardiac arrest patients (VF) with ROSC Hypothermia x 12 hours vs. normothermia survival with good neurologic outcome (normal to moderate disability) in hypothermia group No difference in mortality 1. NEJM 2002;346: NEJM 2002;346: Induction of Hypothermia Peripheral or surface cooling Fans Cooling blankets Ice packs Surface cooling machines Core cooling Endovascular catheters Infusion of ice-cold (4⁰C) fluids Extracorporeal circulation Intensive Care Med, (5): Crit Care Med, (3): Pharmacological Options Against Shivering Paralytics General anesthetics (i.e. propofol) Opioids (meperidine, fentanyl) α 2 -agonists (clonidine, dexmedetomidine) 5-HT agonists/antagonists (buspirone, tramadol) NMDA antagonists (magnesium, ketamine) Midazolam Shivering threshold New shivering threshold Crit Care Med, (7S):S

10 Keys to Successful ACLS Emphasis on high quality CPR Rapid defibrillation for VF / VT Secondary interventions Advanced airway Medications Post-cardiac arrest care ACLS: Pulseless Arrest Suprat Saely, PharmD, BCPS Clinical Pharmacist Specialist, Emergency Medicine December 2, 2013 REPS EC SAG 4 10