Cardiovascular response to epinephrine varies with increasing duration of cardiac arrest
|
|
- Betty Wilson
- 8 years ago
- Views:
Transcription
1 Resuscitation (2008) 77, available at journal homepage: EXPERIMENTAL PAPER Cardiovascular response to epinephrine varies with increasing duration of cardiac arrest Mark G. Angelos a,b,, Ryan L. Butke a, Ashish R. Panchal a, Carlos A.A. Torres a, Alan Blumberg a, Jim E. Schneider a, Sverre E. Aune a a Department of Emergency Medicine, The Ohio State University, Columbus, OH, United States b Davis Heart and Lung Research Institute, The Ohio State University, Columbus, OH, United States Received 19 June 2007; received in revised form 23 October 2007; accepted 26 October 2007 KEYWORDS Cardiopulmonary resuscitation (CPR); Epinephrine; Adrenaline; Return of spontaneous circulation; Post-resuscitation period Summary Objective: Epinephrine (adrenaline) is widely used as a primary adjuvant for improving perfusion pressure and resuscitation rates during cardiopulmonary resuscitation (CPR). Epinephrine is also associated with significant myocardial dysfunction in the post-resuscitation period. We tested the hypothesis that the cardiac effects of epinephrine vary according to the duration of cardiac arrest. Methods and materials: Cardiac arrest (CA) was induced in Sprague Dawley rats with an IV bolus of KCl (40 g/g). Three series of experiments were performed with CPR begun after 2, 4, or 6 min of cardiac arrest. Epinephrine (0.01 mg/kg) IV or placebo was given immediately in the 2 and 4 min CA groups. In the 6 min group, CPR was started after 6 min CA and epinephrine was given at 15 min if no return of spontaneous circulation (ROSC) occurred. Time to ROSC was recorded in all groups. Cardiac function was determined with trans-thoracic echocardiography at baseline, 5, 30 and 60 min after ROSC. Results: After 2 min CA, 8/8 (100%) placebo animals and 8/8 (100%) epinephrine animals attained ROSC. Cardiac index was significantly increased during the first 60 min in the epinephrine group compared with the placebo group (p < 0.01). After 4 min of cardiac arrest, 14/29 (48%) placebo animals and 14/16 (88%) epinephrine animals attained ROSC (p < 0.01). Cardiac index after ROSC returned to baseline in both groups, although tended to be lower in the epinephrine group. After 6 min CA, 10/31 (32%) animals attained ROSC without epinephrine and 17/21 (81%) animals with A Spanish translated version of the summary of this article appears as Appendix in the final online version at doi: /j.resuscitation Corresponding author at: Department of Emergency Medicine and Davis Heart and Lung Research Institute, The Ohio State University, 146 Means Hall, 1654 Upham Drive, Columbus, OH 43210, United States. Tel.: ; fax: address: angelos.1@osu.edu (M.G. Angelos) /$ see front matter 2007 Elsevier Ireland Ltd. All rights reserved. doi: /j.resuscitation
2 102 M.G. Angelos et al. epinephrine (p < 0.01). Post-ROSC depression of cardiac index was greatest in the epinephrine group (p < 0.05). Conclusions: As the duration of cardiac arrest increases, a paradoxical myocardial epinephrine response develops, in which epinephrine becomes increasingly more important to attain ROSC, but is increasingly associated with post-rosc myocardial depression Elsevier Ireland Ltd. All rights reserved. Introduction After cardiac arrest with initial return of spontaneous circulation, significant depression of myocardial contractile function occurs frequently. 1 3 Post-resuscitation myocardial dysfunction has been studied primarily in animal models of ventricular fibrillation and asphyxial cardiac arrest, 2,4 supported by observations from clinical medicine. 5 This post-ischemic myocardial dysfunction is a primary contributor to the early post-resuscitation mortality in cardiac arrest patients. 6 It is speculated that preserving post-resuscitative cardiac function will improve long-term cardiac arrest survival. 7 Epinephrine (adrenaline) has long been considered the principal adrenergic agent to improve perfusion during cardiopulmonary resuscitation (CPR) as a result of its alpha adrenergic agonist properties. However, the role of the beta adrenergic effects of epinephrine is less well understood in the setting of cardiac arrest and may be detrimental in the post-resuscitative heart. 8 In earlier work, epinephrine given during CPR, was found to increase myocardial oxygen consumption and worsen the already tenuous ratio of oxygen delivery to oxygen consumption during ventricular fibrillation (VF). 9,10 However, under the high flow reperfusion conditions of cardiopulmonary bypass during VF, we have shown that epinephrine significantly reduces time to restoration of spontaneous circulation (ROSC) and improves functional cardiac recovery when high flow alone fails to restore cardiac function. 11 These studies suggest some variability in the cardiovascular response to epinephrine in accordance with the level of circulation generated during cardiac arrest. The effects of epinephrine are not limited to the CPR period of cardiac arrest, but also have significant effects on myocardial function immediately following ROSC. Past studies with high dose epinephrine have noted severe adrenergic side effects in the post-cardiac arrest heart attributed to epinephrine. 8,12 Although, not well understood, the effect of epinephrine on the post-arrest heart is likely to vary depending on the severity of the preceding ischemic injury. Indeed, in an asphyxial rat cardiac arrest model, shorting the duration of asphyxia results in improved recovery of contractile function and acidosis following initial resuscitation. 4 Certainly, the duration of cardiac arrest is a principal determinant in obtaining ROSC, even when key outcome measures of perfusion such as coronary perfusion pressure and end tidal CO 2 do not differ. 13 In this study we tested the hypothesis that epinephrine s effects on ROSC success and post-rosc myocardial function vary with the duration of cardiac arrest preceding its administration. Materials and methods Model Sprague Dawley rats weighing approximately g (Harlan, Indianapolis, IN) were used in accordance with the guide for Care and Use of Laboratory Animals published by the US National Institutes of Health (NIH publication No , revised 1996) and the approval of the University Laboratory Animal Resources Committee. Animals were fasted overnight and anesthetized with intraperitoneal pentobarbital (50 mg/kg) and intubated with a 16-gauge catheter (angiocath) via a tracheotomy. Animals were ventilated at 75 breaths/min using a rodent ventilator (Harvard Model 683, South Natick, MA) with a FiO 2 of 0.21 and a tidal volume of 0.65 ml/100 mg body weight to maintain arterial blood gases in the normal range (po 2 >80mmHg, pco mm Hg, and ph ). The jugular vein and femoral artery were cannulated with a 24-gauge catheter (angiocath) and sutured in place. Continuous arterial pressure was measured in the femoral artery. Animals were heparinized (1000 U kg 1 bolus). Arterial pressure and heart rate were recorded continuously using an on-line data acquisition system (Digi-Med Heart Performance Analyzer). Rectal temperature was maintained between 36.5 and 37.5 C throughout the duration of the experiment with a heating lamp. Using a standardized cardiac arrest model, 14 adapted to the rat, cardiac arrest was induced by infusing a bolus of potassium chloride (40 g/g KCl) into the jugular vein followed by a 0.2 ml bolus of saline to ensure that the full KCl dose was delivered to the heart. Ventilation was discontinued simultaneously. Cardiac arrest was confirmed by the loss of the arterial trace with a MAP of <20 mm Hg. Manual chest compressions were started after the pre-determined cardiac arrest duration at a rate of /min with ventilation at 25 breaths/min. Rate and force of compression were maintained by continuous observation of the arterial wave form generated during the CPR period. Epinephrine, based on current recommended weight-based dose (0.01 mg/kg), 15 was given via the jugular vein at the pre-determined time during CPR. CPR was continued until the ROSC, defined as the time of return of a spontaneous arterial blood pressure tracing with a MAP of >60 mm Hg without chest compressions. Following ROSC, all animals received identical care consisting of mechanical ventilation with 100% O 2 at prearrest values and continuous arterial blood pressure, heart rate and temperature monitoring for 60 min. Animals were given a further dose of pentobarbital if there were any signs of awakening. Fluid administration consisted of intermittent 1 ml boluses of normal saline if the animal developed hypotension (MAP < 60 mm Hg). At the conclusion of the
3 Cardiovascular response to epinephrine min-monitoring period, animals were sacrificed painlessly with pentobarbital. Study protocols Three cardiac arrest series were performed (Figure 1) to determine the effects of epinephrine on recovery of myocardial function following ROSC after different durations of cardiac arrest. In each series of experiments, the same KCl rat cardiac arrest model, anesthetic, single dose of epinephrine, CPR methods and post-resuscitation support were used. Series were done sequentially. In series 1, epinephrine (0.01 mg/kg) or placebo (normal saline) was given in a blinded fashion after 2 min of untreated cardiac arrest and CPR was provided until ROSC or the duration of cardiac arrest exceeded 15 min. In series 2, epinephrine (0.01 mg/kg) or placebo (normal saline) was given in a blinded fashion after 4 min of untreated cardiac arrest and CPR was provided until ROSC or the duration of cardiac arrest exceeded 15 min. In series 3, CPR was started after 6 min of untreated cardiac arrest and continued until ROSC or 15 min of cardiac arrest. If no ROSC was attained at 15 min, then epinephrine (0.01 mg/kg), was given and CPR was continued until ROSC or until the duration of cardiac arrest exceeded 20 min. In this series, epinephrine was given as a rescue therapy after a longer cardiac arrest duration and outcome compared to the shorter non-epinephrine group. Echocardiography Trans-thoracic echocardiographic examination of myocardial function was completed pre- and post-cardiac arrest using standard echocardiographic methods. 16 Animals were examined in the supine position after the chest was shaved and a layer of acoustic gel was applied. 2D and M-mode measurements were made with a Vivid 7 Ultrasound machine (GE Medical Systems, Horten, Norway) using an 11 MHz probe. Views were taken after optimization of gain, angulation, and rotation. M-mode measurements were made at or just below the level of the papillary muscles. Ultrasound measurements obtained included, LV posterior wall and chamber diameter during systole (LVIDs) and diastole (LVIDd) and heart rate. Calculations of cardiac output were made by machine software utilizing the formula below described previously by Teichholz et al. 17 cardiac output = (diastolic volume systolic volume) heart rate 1000 diastolic volume = systolic volume = (1) LVIDd (LVIDd)3 (2) LVIDs (LVIDs)3 (3) Figure 1 Experimental protocols. Three series of experiments were performed. In series 1, following a 2 min KCl-induced cardiac arrest, CPR was started and epinephrine (0.01 mg/kg) or placebo was given. In series 2, animals underwent a 4 min KCl-induced cardiac arrest at which time CPR was started and epinephrine (0.01 mg/kg) or placebo was given. In series 3, animals underwent a 6 min KCl-induced cardiac arrest, with CPR until ROSC or 15 min at which time epinephrine (0.01 mg/kg) was given. CA = cardiac arrest, EPI = epinephrine, PL = placebo, ROSC = restoration of spontaneous circulation.
4 104 M.G. Angelos et al. Outcome measures Table 1 Baseline group comparisons of CA survivors Ultrasound measurements were determined at baseline, 5, 30 and 60 min following ROSC. Arterial pressure, heart rate and temperature were measured continuously throughout the study. Arterial blood gases, drawn at baseline, following ROSC and at 60 min post-rosc, were measured on a blood gas analyzer (Critical Care Laboratory Synthesis 45, IL). ROSC rates and time to ROSC were determined in each group. Data analysis Data are presented as mean ± SEM. ROSC rates were determined and compared within series using Mann Whitney U-test. Parametric data were analyzed within series using a one-way analysis of variance followed by a Tukey post hoc test with p < 0.05 set as significant. Results There were no baseline group differences within each series in weight, pentobarbital dose or fluid requirements (Table 1). Echocardiographic evaluation of left ventricular function was performed in all animals. Representative echocardiographic images pre-arrest and 5 min post-rosc illustrate the early change in LV function following resuscitation from cardiac arrest in an animal receiving epinephrine in the 4 min series (Figure 2). After a short cardiac arrest duration of 2 min before starting CPR, ROSC with 60 min survival was 100% in both epinephrine (8/8) and non-epinephrine (8/8) groups (Figure 3a). However, with increasing cardiac arrest dura- Series 1: (2 min CA) No EPI (n = 8) EPI (n =8) Weight (g) ± ± 9.9 Pentobarbital (ml) 0.60 ± ± 0.0 Fluids-pre-arrest (ml) 2.20 ± ± 0.31 Frequency of ROSC 8/8 8/8 ROSC time (min) 2:40 ± 0:11 2:23 ± 0:06 Fluids-post-arrest (ml) 2.30 ± ± 0.81 Series 2: (4 min CA) No EPI (n = 14) EPI (n = 14) Weight (g) ± ± 7.4 Pentobarbital (ml) 0.57 ± ± 0.02 Fluids-pre-arrest (ml) 1.4 ± ± 0.16 Frequency of ROSC 14/29 14/16* ROSC time (min) 5:16 ± 0:18 5:17 ± 0:14 Fluids-post-arrest (ml) 2.2 ± ± 0.2 Series 3: (6 min CA) No EPI (n = 10) EPI (n = 17) Weight (g) ± ± 7.4 Pentobarbital (ml) 0.53 ± ± 0.03 Fluids-pre-arrest (ml) 2.84 ± ± 0.29 Frequency of ROSC 10/31 17/21* ROSC time (min) 11:50 ± 1:28 16:54 ± 0:08 Fluids-post-arrest (ml) 7.5 ± ± 1.3* All animals completed the 60 min post-resuscitation protocol. ROSC rates were significantly higher in the EPI groups after both 4 and 6 min CA. ROSC times were similar within series except for the 6 min CA series, in which the EPI group was longer by design. CA = cardiac arrest, EPI = epinephrine, ROSC = restoration of spontaneous circulation (*p < 0.05 between EPI and no EPI groups). Table 2a 60 min survivor outcome after 2 min cardiac arrest (series 1) Group Baseline ROSC 5 min ROSC 30 min ROSC 60 min Heart rate Placebo 390 ± ± ± ± 29 Epi 378 ± ± ± ± 14 SV (ml) Placebo 0.28 ± ± ± ± 0.04 Epi 0.25 ± ± ± ± 0.04* EF (%) Placebo 83.6 ± ± ± ± 5.0 Epi 88.1 ± ± ± 3.8* 53.0 ± 5.8* CI (L/(min kg)) Placebo ± ± ± ± Epi ± ± ± 0.034* ± 0.032* FS (%) Placebo 48.3 ± ± ± ± 7.2 Epi 53.6 ± ± ± 2.7* 23.5 ± 4.6* ph Placebo 7.49 ± ± ± 0.05 Epi 7.49 ± ± ± 0.05 P a CO 2 Placebo 32 ± 2 50 ± 6 37 ± 6 Epi 29 ± 2 32 ± 6 39 ± 2 P a O 2 (FiO 2 ) Placebo 82 ± 7 (0.21) 245 ± 79 (1.0) 402 ± 52 (1.0) Epi 91 ± 4 (0.21) 227 ± 51 (1.0) 335 ± 69 (1.0) Hct Placebo 41 ± 2 42 ± 1 37 ± 6 Epi 41 ± 2 43 ± 3 39 ± 2 Syst art press Placebo 162 ± ± ± ± 8 Epi 159 ± ± ± ± 7 *p < 0.05 compared with placebo group (placebo group n = 8, epinephrine group n = 8). SV = stroke volume, CI = cardiac index, EF = ejection fraction, FS = fractional shortening, Hct = hematocrit.
5 Cardiovascular response to epinephrine 105 Figure 2 Representative echocardiography at baseline and 60 min following ROSC in a short cardiac arrest (a) with ROSC time of 2:20 and a longer cardiac arrest (b) with a ROSC time of 5:17. Cardiac output following a short cardiac arrest with epinephrine was increased above baseline at 60 min following ROSC (a) in contrast to a lower than baseline cardiac output after a longer cardiac arrest with epinephrine (b). Trans-thoracic 2D and M-mode short axis views of the left ventricle were obtained at the level of the papillary muscles. tion before CPR (4 min), ROSC rates were significantly higher with epinephrine compared to non-epinephrine groups (Figure 3a). With still longer durations of cardiac arrest before beginning CPR (6 min), ROSC was successful only 32% of the time without epinephrine, but 81% successful with epinephrine in this same group initially refractory to ROSC with CPR only (Figure 3a). In all three series, animals attaining ROSC survived to 60 min. ROSC times were similar between epinephrine and non-epinephrine groups after 2 and 4 min CA, but were significantly longer in the epinephrine group after 6 min of cardiac arrest by design (see Table 1). Relative to baseline, cardiac index at 60 min post-rosc was increased in the epinephrine group in the 2 min series, unchanged in the 4 min series and significantly depressed in the 6 min series (Figure 3b). Following resuscitation from cardiac arrest in the 2 min series, cardiac index was significantly increased in the epinephrine group relative to the non-epinephrine group (Table 2a). This increase in cardiac index was primarily due to an increase in stroke volume (both systolic and diastolic LV volume), but was also accompanied by a reduction in ejection fraction and fractional shortening compared with the non-epinephrine group (Table 2a). Thus, although overall CI was increased, ventricular efficiency (ejection fraction) was decreased, indicating some degree of myocardial dysfunction. In the 4 min series, the cardiac index increased transiently in both groups but returned to baseline cardiac index by 60 min (Table 2b). In this series, stroke volume was largely unchanged in both groups (Table 2b). In the 6 min series, the cardiac index was significantly decreased in the non-epinephrine and epinephrine group compared with baseline; however the
6 106 M.G. Angelos et al. Figure 2 (Continued ). depression in the epinephrine group was greater relative to the non-epinephrine group (Table 2c). Within the 6 min epinephrine group, a significant reduction in heart rate and a greater metabolic acidosis was present compared with the non-epinephrine group. Discussion The present study demonstrates the variable and discordant effects of epinephrine on initial resuscitation rates and myocardial dysfunction after varying durations of cardiac arrest. Utilizing a standardized cardiac arrest model and current 2005 American Heart Association recommended weight-based epinephrine dose, 15 we noted equal resuscitation rates with or without epinephrine after very short durations of cardiac arrest, but significant improvement in initial resuscitation rates with epinephrine, as the duration of cardiac arrest increased. Concurrently, we noted increased myocardial depression in the post-resuscitation period with epinephrine as the duration of cardiac arrest increased. In clinical cardiac arrest, the greatest percentage of resuscitation failures consists of the inability to restart the heart, i.e. to obtain ROSC. Data from the National Registry of Cardiopulmonary Resuscitation show that of 14,720 in-hospital cardiac arrests, only 44% had restoration of spontaneous circulation and 17% survived to hospital discharge. 18 Similarly, in out-of-hospital cardiac arrest victims, an initial return of spontaneous circulation occurs in only about 30%. 19 Consequently, approximately 70% of cardiac arrest victims never recover any functional contractile heart activity despite CPR and other interventions. Epinephrine or the non-adrenergic agent, vasopressin, are currently the recommended agents to improve initial resuscitation rates in all cardiac arrest rhythms, including electrically susceptible rhythms if initial defibrillation fails. 15 However, epinephrine has been associated with increased myocardial depression in the early post-resuscitation period, particularly with in high doses. 8,12
7 Cardiovascular response to epinephrine 107 Table 2b 60 min survivor outcome after 4 min cardiac arrest (series 2) Group Baseline ROSC 5 min ROSC 30 min ROSC 60 min Heart rate Placebo 358 ± ± ± ± 16 Epi 368 ± ± ± ± 16 SV (ml) Placebo 0.32 ± ± ± ± 0.04 Epi 0.30 ± ± ± ± 0.04 EF (%) Placebo 83.5 ± ± ± ± 4.8 Epi 79.2 ± ± ± ± 4.8 CI (L/(min kg)) Placebo ± ± ± ± Epi ± ± ± ± FS (%) Placebo 47.5 ± ± ± ± 4.2 Epi 42.7 ± ± ± ± 2.5 ph Placebo 7.45 ± ± ± 0.02 Epi 7.50 ± ± ± 0.05 P a CO 2 Placebo 35 ± 3 59 ± 5 40 ± 2 Epi 30 ± 1 57 ± 4 32 ± 3 P a O 2 (FiO 2 ) Placebo 148 ± 60 (0.21) 88 ± 22 (1.0) 202 ± 48(1.0) Epi 101 ± 6 (0.21) 117 ± 20 (1.0) 282 ± 33(1.0) Hct Placebo 44 ± 2 41 ± 2 44 ± 2 Epi 45 ± 1 45 ± 1 45 ± 1 Syst art press Placebo 146 ± ± ± ± 30 Epi 171 ± ± ± ± 8 There were no significant differences between groups (placebo group n = 12, epinephrine group n = 14). SV = stroke volume, CI = cardiac index, EF = ejection fraction, FS = fractional shortening, Hct = hematocrit. Using non-invasive echocardiographic measures of LV function, the present study demonstrates that significant myocardial depression occurs in the early post-cardiac arrest period after relatively short durations of cardiac arrest with and without the use of epinephrine. In previous studies, myocardial dysfunction following resuscitation from cardiac arrest has been characterized by decreased LV ejection fraction, fractional shortening, dp/dt 40 and increased tau (isovolumetric relaxation time). 5,20 In this study, epinephrine was associated with an increased cardiac output state after a very short cardiac arrest, mild reversible myocardial depression after a slightly longer cardiac arrest Table 2c 60 min survivor outcome after 6 min cardiac arrest (series 3) Group Baseline ROSC 5 min ROSC 30 min ROSC 60 min Heart rate Placebo 353 ± ± ± ± 29 Epi 358 ± ± 23* 272 ± 18* 267 ± 17* SV (ml) Placebo 0.26 ± ± ± ± 0.04 Epi 0.29 ± ± ± ± 0.03 EF (%) Placebo 85 ± 3 94 ± 5 88 ± 3 89 ± 4 Epi 83 ± 2 72 ± ± 5 76 ± 9 CI (L/(min kg)) Placebo ± ± ± ± Epi ± ± 0.025* ± ± FS (%) Placebo 50 ± 5 77 ± ± 5 59 ± 6 Epi 47 ± 2 48 ± 5 46 ± 5 52 ± 8 ph Placebo 7.46 ± ± ± 0.06 Epi 7.39 ± ± ± 0.02* P a CO 2 Placebo 33 ± 3 51 ± 6 40 ± 6 Epi 37 ± 2 55 ± 7 32 ± 4 P a O 2 (FiO 2 ) Placebo 120 ± ± 56 (1.0) 393 ± 52 (1.0) Epi 87 ± 5 (0.21) 76 ± 20 (1.0) 317 ± 36 (1.0) Hct Placebo 44 ± 2 39 ± 2 33 ± 4 Epi 44 ± 1 39 ± 2 39 ± 3 Syst art press Placebo 147 ± ± ± 8 91 ± 8 Epi 137 ± ± 16* 135 ± 10* 120 ± 8* *p < 0.05 compared with placebo group (placebo group n = 10, epinephrine group n = 17). SV = stroke volume, CI = cardiac index, EF = ejection fraction, FS = fractional shortening, Hct = hematocrit.
8 108 M.G. Angelos et al. Figure 3 (a) The rate of restoration of spontaneous circulation (ROSC) is shown as both a fraction and percentage in each of the three series with and without epinephrine. There was no difference in ROSC rates when epinephrine was given after 2 min of cardiac arrest. However, with lengthening cardiac arrest times, ROSC rates were significantly higher in animals receiving epinephrine after 4 min (*p < 0.05) and 6 min ( p < 0.01) of cardiac arrest. (b) Cardiac index at 60 min post-resuscitation period with and without epinephrine in survivors following cardiac arrest times of 2, 4 and 6 min before starting CPR. The cardiac index increased significantly in the epinephrine group compared with the non-epinephrine group following ROSC in the 2 min series (*p < 0.05), and then decreased relative to the non-epinephrine group in the 4 min series (p = 0.06). In the 6 min series, the cardiac index was depressed in both epinephrine and non-epinephrine groups, but was more severe in the epinephrine group ( p < 0.05). The cardiac index at 60 min is expressed as botha%ofbaseline in each group and in L/(kg min). and more severe myocardial depression noted after a more prolonged cardiac arrest. As the epinephrine dose and CPR were similar in all groups, the differences in post-arrest LV function were primarily a function of the duration of cardiac arrest. The duration of cardiac arrest is then a key determinant of the cardiovascular response of epinephrine in cardiac arrest. As, epinephrine has both important preand post-rosc effects on the myocardium in the setting of cardiac arrest, any depression in post-myocardial function induced by epinephrine must be balanced against any improvement in ROSC rates associated with epinephrine. Indeed it is the pre-rosc effect, for which epinephrine is indicated, although the effects of epinephrine given during cardiac arrest may persist after ROSC. Recent studies have again highlighted the potential adverse effects of epinephrine during cardiac arrest. In the pediatric cardiac arrest population, epinephrine doses of >15 g/kg were associated with an increased incidence of secondary VF, with worse outcome than primary VF. 21 In an adult out-of-hospital cardiac arrest population resuscitated successfully with early myocardial dysfunction, epinephrine was noted to be an independent factor for low ejection fraction. 22 The effect of epinephrine on the microcirculation may be an important factor in the early post-resuscitation period. Utilizing direct visualization of the sublingual capillary bed in a swine cardiac arrest model, a significant decrease in microcirculatory blood flow was noted in animals receiving epinephrine (25 g/kg). 23 This decrease was most pronounced in the first minutes following ROSC. If a similar response is found to occur in the microcirculatory flow of the myocardium after epinephrine, this could contribute to the decreased myocardial function observed. As expected with a short arrest time, there was no advantage with epinephrine during cardiac arrest. Of note, however, is the absence of cardio-depressant effects with epinephrine in the short arrest period as has been reported after longer cardiac arrests and higher doses of epinephrine. This increase in cardiac output and absence of early mortality is in contrast to a recent report of increased mortality and myocardial depression after a 1 min asphyxial rat cardiac arrest with 10 or 30 g/kg epinephrine. 24 Compared to this study we used the lower epinephrine dose, 10 g/kg and a non-asphyxial model of cardiac arrest. However, despite the increased cardiac output state noted in the 2 min epinephrine group, a significant increase in ventricular volume and a decrease in ejection fraction were noted simultaneously. These findings suggest some degree of myocardial dysfunction, albeit compensated, was present following epinephrine. An important limitation of this study is the relatively short study time frame following ROSC, which does not allow for assessment of the duration and full extent of myocardial dysfunction over time. Instead the focus of this study was on the early post-rosc myocardial depression which occurs during the very vulnerable time when a significant portion of cardiac arrest patients initially achieve ROSC, but then re-arrest and die prior to hospital admission. In a recent study only 47% of out-of-hospital cardiac arrest patients in whom ROSC was obtained survived to hospital admission. 25 This study reaffirms the importance of early epinephrine to facilitate ROSC and highlights the epinephrine dichotomy in cardiac arrest. This dichotomous epinephrine response is based on the observations that the longer the duration of cardiac arrest, the more difficult to achieve ROSC and thus the greater need for epinephrine. However, as the duration of cardiac arrest increases, the benefit of epinephrine to attain ROSC is offset by increased epinephrine mediated post-arrest myocardial dysfunction. Achieving ROSC is the first priority in cardiac arrest and only then can the secondary problem of post-arrest myocardial dysfunction be addressed. Not surprising both issues are largely dependent on the duration of cardiac arrest. Currently
9 Cardiovascular response to epinephrine 109 the recommended guidelines for epinephrine use during cardiac arrest call for the same epinephrine dose for all cardiac arrest conditions. As noted in this study, the effect of this same dose concentration is likely to vary depending on a number of factors including duration of cardiac arrest, but also likely vary according to various factors which affect the level of CPR generated blood flow. Support for this premise is found in a recent study in a swine cardiac arrest model in which epinephrine (0.02 mg/kg) was given during different chest compression protocols and significant differences in epinephrine plasma concentrations, coronary perfusion pressure, cerebral and femoral blood flow were noted during CPR. 26 Ultimately, optimization of epinephrine (or other adrenergic agents) doses during cardiac arrest must vary in accordance with specific cardiac arrest factors, such as length of arrest. Recent studies have focused on use of selective alpha-2 adrenergic agents to promote ROSC in cardiac arrest but minimize effects on postarrest myocardial function. 27,28 These agents may yet be an alternative to epinephrine use in cardiac arrest. However, more work is needed to understand the effects of these agents in the post-arrest setting, before they can be recommended. Conclusions As the duration of cardiac arrest increases, a paradoxical myocardial epinephrine response develops, in which epinephrine becomes increasingly more important for ROSC, but is increasingly associated with post-rosc myocardial depression. This study demonstrates both the benefit and detriment of epinephrine in cardiac arrest over time and re-emphasizes the need for short acting agents designed to improve ROSC without depressing post-myocardial function. Conflict of interest None. Acknowledgements This research was supported by the Roessler Scholarship Fund, Ohio State University (RL Butke), SAEM Institutional Research Training Award (CA Torres) and Ohio State Strategic Initiatives Grant and the American Heart Association Ohio Affiliate (MG Angelos). References 1. Kern KB, Hilwig RW, Berg RA, et al. Postresuscitation left ventricular systolic and diastolic dysfunction. Treatment with dobutamine. Circulation 1997;95: Tang W, Weil MH, Sun S, Gazmuri RJ, Bisera J. Progressive myocardial dysfunction after cardiac resuscitation. Crit Care Med 1993;21: Klouche K, Weil MH, Sun S, Tang W, Zhao DH. A comparison of alpha-methylnorepinephrine, vasopressin and epinephrine for cardiac resuscitation. Resuscitation 2003;57: McCaul CL, McNamara P, Engelberts D, Slorach C, Hornberger LK, Kavanagh BP. The effect of global hypoxia on myocardial function after successful cardiopulmonary resuscitation in a laboratory model. Resuscitation 2006;68: Kern KB, Hilwig RW, Rhee KH, Berg RA. Myocardial dysfunction after resuscitation from cardiac arrest: an example of global myocardial stunning. J Am Coll Cardiol 1996;28: Kern KB. Postresuscitation myocardial dysfunction. Cardiol Clin 2002;20: Sun S, Weil MH, Tang W, Kamohara T, Klouche K. Deltaopioid receptor agonist reduces severity of postresuscitation myocardial dysfunction. Am J Physiol Heart Circ Physiol 2004;287:H Tang W, Weil MH, Sun S, Noc M, Yang L, Gazmuri RJ. Epinephrine increases the severity of postresuscitation myocardial dysfunction. Circulation 1995;92: Ditchey RV, Lindenfeld J. Failure of epinephrine to improve the balance between myocardial oxygen supply and demand during closed-chest resuscitation in dogs. Circulation 1988;78: Lindner KH, Ahnefeld FW, Schuermann W, Bowdler IM. Epinephrine and norepinephrine in cardiopulmonary resuscitation. Effects on myocardial oxygen delivery and consumption. Chest 1990;97: Angelos MG, DeBehnke DJ. Epinephrine and high-flow reperfusion after cardiac arrest in a canine model. Ann Emerg Med 1995;1926: Berg RA, Otto CW, Kern KB, et al. High-dose epinephrine results in greater early mortality after resuscitation from prolonged cardiac arrest in pigs: a prospective, randomized study. Crit Care Med 1994;22: Duggal C, Weil MH, Tang W, Gazmuri RJ, Sun S. Effect of arrest time on the hemodynamic efficacy of precordial compression. Crit Care Med 1995;23: Abella BS, Zhao D, Alvarado J, Hamann K, Vanden Hoek TL, Becker LB. Intra-arrest cooling improves outcomes in a murine cardiac arrest model. Circulation 2004;109: American Heart Association (2005). Guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2005;112(IV1): Feigenbaum H. Echocardiography. Philadelphia, PA; Teichholz LE, Kreulen T, Herman MV, Gorlin R. Problems in echocardiographic volume determinations: echocardiographicangiographic correlations in the presence of absence of asynergy. Am J Cardiol 1976;37: Peberdy MA, Kaye W, Ornato JP, et al. Cardiopulmonary resuscitation of adults in the hospital: a report of cardiac arrests from the National Registry of Cardiopulmonary Resuscitation. Resuscitation 2003;58: Eisenberg MS, Mengert TJ. Cardiac resuscitation. N Engl J Med 2001;344: Gazmuri RJ, Weil MH, Bisera J, Tang W, Fukui M, McKee D. Myocardial dysfunction after successful resuscitation from cardiac arrest. Crit Care Med 1996;24: Tibballs J, Kinney S. A prospective study of outcome of in-patient paediatric cardiopulmonary arrest. Resuscitation 2006;71: Chang WT, Ma MH, Chien KL, et al. Postresuscitation myocardial dysfunction: correlated factors and prognostic implications. Intensive Care Med November 15 [epub ahead of print]. 23. Fries M, Weil MH, Chang YT, Castillo C, Tang W. Microcirculation during cardiac arrest and resuscitation. Crit Care Med 2006;34:S McCaul CL, McNamara PJ, Engelberts D, et al. Epinephrine increases mortality after brief asphyxial cardiac arrest in an in vivo rat model. Anesth Analg 2006;102: Ong ME, Ornato JP, Edwards DP, et al. Use of an automated, loaddistributing band chest compression device for out-of-hospital
10 110 M.G. Angelos et al. cardiac arrest resuscitation. JAMA 2006;295(22): June Pytte M, Kramer-Johansen J, Eilevstjonn J, et al. Haemodynamic effects of adrenaline (epinephrine) depend on chest compression quality during cardiopulmonary resuscitation in pigs. Resuscitation 2006;71: Klouch K, Weil MH, Tang W, et al. A selective alpha2- adrenergic agonist for cardiac resuscitation. J Lab Clin Med 2002;140: Klouche K, Weil MH, Sun S, et al. A comparison of alphamethylnorepinephrine, vasopressin and epinephrine for cardiac resuscitation. Resuscitation 2003;57:
Update on Small Animal Cardiopulmonary Resuscitation (CPR)- is anything new?
Update on Small Animal Cardiopulmonary Resuscitation (CPR)- is anything new? DVM, DACVA Objective: Update on the new Small animal guidelines for CPR and a discussion of the 2012 Reassessment Campaign on
More informationWhat is the Future of Epinephrine in Cardiac Arrest? Pros and Cons
What is the Future of Epinephrine in Cardiac Arrest? Pros and Cons Melissa L. Thompson Bastin, PharmD., BCPS Komal A. Pandya, PharmD., BCPS 0 Presenter Disclosure Information Melissa L. Thompson Bastin,
More informationImpact of Manual CPR on Increasing Coronary Perfusion Pressure
Impact of Manual CPR on Increasing Coronary Perfusion Pressure In sudden cardiac arrest cases, the ability to adequately perfuse the brain and heart during resuscitation is of critical importance. The
More informationPatient Schematic. Perkins GD et al The Lancet, 385, 2015, 947-955
Lancet March 2015 Patient Schematic Perkins GD et al The Lancet, 385, 2015, 947-955 Background Adequate CPR is critical for survival for CA patients Maintenance of high-quality compressions during OHCA
More informationHigh Performance CPR Toolkit
Toolkit HIGH PERFORMANCE CPR TOOL KIT This tool kit is free to EMS agencies interested in implementing high performance CPR into their programs. The materials have been developed to provide step-by-step
More informationLocal Anaesthetic Systemic Toxicity. Dr Thomas Engelhardt, MD, PhD, FRCA Royal Aberdeen Children s Hospital, Scotland
Local Anaesthetic Systemic Toxicity Dr Thomas Engelhardt, MD, PhD, FRCA Royal Aberdeen Children s Hospital, Scotland Conflict of interest None Overview Local anesthetic systemic toxicity (LAST) Background
More informationThe role of epinephrine during cardiopulmonary resuscitation
Repeated Administration of Vasopressin but Not Epinephrine Maintains Coronary Perfusion Pressure After Early and Late Administration During Prolonged Cardiopulmonary Resuscitation in Pigs Volker Wenzel,
More informationCardiac Arrest Pediatric Ventricular Fibrillation / Pulseless Ventricular Tachycardia Protocol revised October 2008
Cardiac Arrest Pediatric Ventricular Fibrillation / Pulseless Ventricular Tachycardia Protocol revised October 2008 Preamble In contrast to cardiac arrest in adults, cardiopulmonary arrest in pediatric
More informationCardiac Arrest VF/Pulseless VT Learning Station Checklist
Cardiac Arrest VF/Pulseless VT Learning Station Checklist VF/VT 00 American Heart Association Adult Cardiac Arrest Shout for Help/Activate Emergency Response Epinephrine every - min Amiodarone Start CPR
More informationMedical Direction and Practices Board WHITE PAPER
Medical Direction and Practices Board WHITE PAPER Use of Pressors in Pre-Hospital Medicine: Proper Indication and State of the Science Regarding Proper Choice of Pressor BACKGROUND Shock is caused by a
More informationA Comparison of High-Dose and Standard-Dose Epinephrine in Children with Cardiac Arrest
The new england journal of medicine original article A Comparison of High-Dose and Standard-Dose Epinephrine in Children with Cardiac Arrest Maria Beatriz M. Perondi, M.D., Amelia G. Reis, M.D., Ph.D.,
More informationAdding IV Amiodarone to the EMS Algorithm for Cardiac Arrest Due to VF/Pulseless VT
Adding IV Amiodarone to the EMS Algorithm for Cardiac Arrest Due to VF/Pulseless VT Introduction Before the year 2000, the traditional antiarrhythmic agents (lidocaine, bretylium, magnesium sulfate, procainamide,
More informationACLS PRE-TEST ANNOTATED ANSWER KEY
ACLS PRE-TEST ANNOTATED ANSWER KEY June, 2011 Question 1: Question 2: There is no pulse with this rhythm. Question 3: Question 4: Question 5: Question 6: Question 7: Question 8: Question 9: Question 10:
More informationAktuelle Literatur aus der Notfallmedizin
05.02.2014 Aktuelle Literatur aus der Notfallmedizin prä- und innerklinisch Aktuelle Publikationen aus 2012 / 2013 PubMed hits zu emergency medicine 12,599 Abstract OBJECTIVES: Current American Heart
More informationThe Sepsis Puzzle: Identification, Monitoring and Early Goal Directed Therapy
The Sepsis Puzzle: Identification, Monitoring and Early Goal Directed Therapy Cindy Goodrich RN, MS, CCRN Content Description Sepsis is caused by widespread tissue injury and systemic inflammation resulting
More informationManagement of Pediatric Emergencies: Current Evidence from Cochrane/ other Systematic Reviews
Indian Journal of Emergency Pediatrics 119 Volume 3 Number 3, July - September 2011 Management of Pediatric Emergencies: Current Evidence from Cochrane/ other Systematic Reviews Clinical Question: Is Vasopressin
More informationResuscitation 82 (2011) 1138 1143. Contents lists available at ScienceDirect. Resuscitation
Resuscitation 82 (2011) 1138 1143 Contents lists available at ScienceDirect Resuscitation j ourna l h o me pag e: www. elsevier.com/locate/resuscitation Clinical paper Effect of adrenaline on survival
More informationDEBRIEFING GUIDE. The key components of an optimal code response: 1. Early recognition that the patient is deteriorating or has become unresponsive.
DEBRIEFING GUIDE I N T R O D U C T I O N Debriefing has been shown to improve clinical behavior during cardiac resuscitation and, as such, has become a recommended procedure in the 2010 American Heart
More informationEpinephrine, Sodium Bicarbonate and Calcium
Home SVCC Area: English - Español - Português Epinephrine, Sodium Bicarbonate and Calcium Alfredo Sierra Unzueta, MD Unidad de Terapia Intensiva "Alberto Villazón S", Hospital Español de México, México
More informationACLS PHARMACOLOGY 2011 Guidelines
ACLS PHARMACOLOGY 2011 Guidelines ADENOSINE Narrow complex tachycardias or wide complex tachycardias that may be supraventricular in nature. It is effective in treating 90% of the reentry arrhythmias.
More informationPaediatric Advanced Life Support
Paediatric Advanced Life Support Introduction There is concern that resuscitation from cardiac arrest is not performed as well as it might because the variations in guidelines for different age groups
More informationEvolving Role of Vasopressin in the Treatment of Cardiac Arrest
Evolving Role of Vasopressin in the Treatment of Cardiac Arrest Todd A. Miano, Pharm.D., and Michael A. Crouch, Pharm.D. Sudden cardiac arrest is a major public heath problem, affecting more than 450,000
More informationCardiopulmonary Resuscitation
Cardiopulmonary Resuscitation Jonathan E. Palmer, V.M.D. Author s address: Graham French Neonatal Section, Connelly Intensive Care Unit, New Bolton Center, University of Pennsylvania, 382 West Street Rd.,
More informationCardiac Arrest - Ventricular Fibrillation / Pulseless Ventricular Tachycardia Protocol revised October 2008
Cardiac Arrest - Ventricular Fibrillation / Pulseless Ventricular Tachycardia Protocol revised October 2008 Preamble Survival from cardiorespiratory arrest for patients who present with ventricular fibrillation
More informationANNE ARUNDEL MEDICAL CENTER CRITICAL CARE MEDICATION MANUAL DEPARTMENT OF NURSING AND PHARMACY. Guidelines for Use of Intravenous Isoproterenol
ANNE ARUNDEL MEDICAL CENTER CRITICAL CARE MEDICATION MANUAL DEPARTMENT OF NURSING AND PHARMACY Guidelines for Use of Intravenous Isoproterenol Major Indications Status Asthmaticus As a last resort for
More information2015 Interim Resources for HeartCode ACLS
2015 Interim Resources for HeartCode ACLS Original Release: November 25, 2015 Starting in 2016, new versions of American Heart Association online courses will be released to reflect the changes published
More informationResuscitation 83 (2012) 327 332. Contents lists available at SciVerse ScienceDirect. Resuscitation
Resuscitation 83 (2012) 327 332 Contents lists available at SciVerse ScienceDirect Resuscitation jo u rn al hom epage : www.elsevier.com/locate/resuscitation Clinical Paper Outcome when adrenaline (epinephrine)
More informationPulseless Emergencies
Pulseless Emergencies Nicole M. Acquisto, Pharm.D., BCPS Emergency Medicine Clinical Pharmacy Specialist University of Rochester Medical Center Nothing to disclose Disclosures Objectives Understand the
More informationInotropes/Vasoactive Agents Hina N. Patel, Pharm.D., BCPS Cathy Lawson, Pharm.D., BCPS
Inotropes/Vasoactive Agents Hina N. Patel, Pharm.D., BCPS Cathy Lawson, Pharm.D., BCPS 1. Definition -an agent that affects the contractility of the heart -may be positive (increases contractility) or
More informationImpaired myocardial performance and resuscitation? PEM symposium May 19 th 2009 Patrick McNamara
Impaired myocardial performance and resuscitation? PEM symposium May 19 th 2009 Patrick McNamara Outline Evidence for Resuscitation! Epinephrine and post-resuscitation myocardial function? Resuscitation
More informationSudden Cardiac Arrest- Focusing on the Unsolved Problems
Sudden Cardiac Arrest- Focusing on the Unsolved Problems Wen-Jone Chen MD, PhD, FESC Professor of Medicine, Department of Emergency Medicine, National Taiwan University, Taipei, Taiwan Superintendent,
More informationSeptic Shock: Pharmacologic Agents for Hemodynamic Support. Nathan E Cope, PharmD PGY2 Critical Care Pharmacy Resident
Septic Shock: Pharmacologic Agents for Hemodynamic Support Nathan E Cope, PharmD PGY2 Critical Care Pharmacy Resident Objectives Define septic shock and briefly review pathophysiology Outline receptor
More informationVASOPRESSOR AGENTS IN SEPTIC SHOCK
VASOPRESSOR AGENTS IN SEPTIC SHOCK Daniel De Backer Head Dept Intensive Care, CHIREC hospitals, Belgium Professor of Intensive Care, Université Libre de Bruxelles President European Society of Intensive
More informationCrash Cart Drugs Drugs used in CPR. Dr. Layla Borham Professor of Clinical Pharmacology Umm Al Qura University
Crash Cart Drugs Drugs used in CPR Dr. Layla Borham Professor of Clinical Pharmacology Umm Al Qura University Introduction A list of the drugs kept in the crash carts. This list has been approved by the
More informationJournal reading. Method. Introduction. Measurement. Supervisor: F1 徐 英 洲 Presentor:R1 劉 邦 民 103.04.14
Journal reading Supervisor: F1 徐 英 洲 Presentor:R1 劉 邦 民 103.04.14 Introduction Epinephrine usage in CPR Pro: Ability to augment BP and increased coronary perfusion through systemic vasoconstriction Cons:
More informationNote: The left and right sides of the heart must pump exactly the same volume of blood when averaged over a period of time
page 1 HEART AS A PUMP A. Functional Anatomy of the Heart 1. Two pumps, arranged in series a. right heart: receives blood from the systemic circulation (via the great veins and vena cava) and pumps blood
More informationHigh dose versus standard dose epinephrine in cardiac arrest a meta-analysis
Resuscitation 45 (2000) 161 166 www.elsevier.com/locate/resuscitation High dose versus standard dose epinephrine in cardiac arrest a meta-analysis C. Vandycke *, P. Martens Department of Emergency Medicine,
More informationPurpose To guide registered nurses who may manage clients experiencing sudden or unexpected life-threatening cardiac emergencies.
Emergency Cardiac Care: Decision Support Tool #1 RN-Initiated Emergency Cardiac Care Without Cardiac Monitoring/Manual Defibrillator or Emergency Cardiac Drugs Decision support tools are evidence-based
More information2015 AHA /ECC updates for BLS: Compression rate and depth - how to perform and monitor
2015 AHA /ECC updates for BLS: Compression rate and depth - how to perform and monitor 范 文 林 醫 師 2016/04/10 Reinforced Chest compressions are the key component of effective CPR. Characteristics of chest
More informationSafe Zone: CV PIP < 26; HFOV: MAP < 16; HFJV: MAP < 16 Dopamine infusion up to 20 mcg/kg/min Epinephrine infusion up to 0.1 mcg /kg/min.
Congenital Diaphragmatic Hernia: Management Guidelines 5-2006 Issued By: Division of Neonatology Reviewed: Effective Date: Categories: Chronicity Document Congenital Diaphragmatic Hernia: Management Guidelines
More informationThe 5 Most Important EMS Articles EAGLES 2014
The 5 Most Important EMS Articles EAGLES 2014 Corey M. Slovis, M.D. Vanderbilt University Medical Center Metro Nashville Fire Department Nashville International Airport Nashville, TN VanderbiltEM.com
More informationRise of the killer peanuts
Rise of the killer peanuts Epi Then, Epi Now Taher Vohra, MD Henry Ford Hospital Department of Emergency Medicine ObjecCves To define anaphylaxis To review the epidemiology of anaphylaxis To discuss treatments
More informationMedical management of CHF: A New Class of Medication. Al Timothy, M.D. Cardiovascular Institute of the South
Medical management of CHF: A New Class of Medication Al Timothy, M.D. Cardiovascular Institute of the South Disclosures Speakers Bureau for Amgen Background Chronic systolic congestive heart failure remains
More informationTHERAPEUTIC INDUCED HYPOTHERMIA GUIDELINES
THERAPEUTIC INDUCED HYPOTHERMIA GUIDELINES Guidelines for Inclusion: (check all that apply) Cardiac arrest patients with any of the following: Ventricular fibrillation Pulseless Ventricular tachycardia
More informationIf you do not wish to print the entire pre-test you may print Page 2 only to write your answers, score your test, and turn in to your instructor.
This is a SAMPLE of the pretest you can access with your AHA PALS Course Manual at Heart.org/Eccstudent using your personal code that comes with your PALS Course Manual The American Heart Association strongly
More informationResuscitation in congenital heart disease. Peter C. Laussen MBBS FCICM Department Critical Care Medicine Hospital for Sick Children Toronto
Resuscitation in congenital heart disease Peter C. Laussen MBBS FCICM Department Critical Care Medicine Hospital for Sick Children Toronto Evolution of Congenital Heart Disease Extraordinary success: Overall
More informationThe vast majority of patients
Sodium nitroprusside enhanced cardiopulmonary resuscitation improves survival with good neurological function in a porcine model of prolonged cardiac arrest* Demetris Yannopoulos, MD; Timothy Matsuura,
More information2015 Interim Resources for BLS
2015 Interim Resources for BLS Original Release: November 25, 2015 Starting in 2016, new versions of American Heart Association online courses will be released to reflect the changes published in the 2015
More informationCARDIAC RESUSCITATION: A compazuson of 30:2 AND ccc cpr on ADMINISTRATION. A Thesis Submitted to the Honors Collese MAY 2011
CARDIAC RESUSCITATION: A compazuson of 30:2 AND ccc cpr on BYSTANDER WILLINGNESS AND THE TIMING AND ROUTE OF EPINEPHRINE ADMINISTRATION By Sarah Nicole Peer A Thesis Submitted to the Honors Collese In
More informationMichigan Adult Cardiac Protocols CARDIAC ARREST GENERAL. Date: May 31, 2012 Page 1 of 5
Date: May 31, 2012 Page 1 of 5 Cardiac Arrest General This protocol should be followed for all adult cardiac arrests. Medical cardiac arrest patients undergoing attempted resuscitation should not be transported
More informationEpinephrine in CPR. The 5 Most Important EMS Articles EAGLES 2014. Epi vs No-Epi Take Homes 2/28/2014. VF/VT (1990 Pairs) Epi vs No-Epi
The 5 Most Important EMS Articles EAGLES 214 Corey M. Slovis, M.D. Vanderbilt University Medical Center Metro Nashville Fire Department Nashville International Airport Nashville, TN nephrine in CPR VF/VT
More informationE C C. American Heart Association. Advanced Cardiovascular Life Support. Written Exams. May 2011
E C C American Heart Association Advanced Cardiovascular Life Support Written Exams Contents: Exam Memo Student Answer Sheet Version A Exam Version A Answer Key Version A Reference Sheet Version B Exam
More informationResuscitation Could this new model of CPR hold promise for better rates of neurologically intact survival?
Cover report by Gordon A. Ewy, MD, Michael J. Kellum, MD, & Bentley J. Bobrow, MD CARDIOCEREBRAL Resuscitation Could this new model of CPR hold promise for better rates of neurologically intact survival?
More informationHow To Know If Epinephrine Helps With A Cardiac Arrest
Review Article 85 Epinephrine in out-of-hospital cardiac arrest: A critical review Peter M. Reardon 1, Kirk Magee 2 1 Dalhousie Medical School, Halifax, B3H 4R2, Nova Scotia, Canada 2 Dalhousie Department
More informationThis article appeared in a journal published by Elsevier. The attached copy is furnished to the author for internal non-commercial research and
This article appeared in a journal published by Elsevier. The attached copy is furnished to the author for internal non-commercial research and education use, including for instruction at the authors institution
More informationOriginal Contributions
doi:10.1016/j.jemermed.2010.02.030 The Journal of Emergency Medicine, Vol. 41, No. 5, pp. 453 459, 2011 Copyright 2011 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ see front matter
More informationHeart matters Cardiovascular events demand quick response
Heart matters Cardiovascular events demand quick response By Kenny Navarro, LP photo by Audra Horton of Merkel EMS If the heart trembles, has little power and sinks, the disease is advancing and death
More informationQuiz 5 Heart Failure scores (n=163)
Quiz 5 Heart Failure summary statistics The correct answers to questions are indicated by *. Students were awarded 2 points for question #3 for either selecting spironolactone or eplerenone. However, the
More informationREVIEW ARTICLE. arrest is a major public health
REVIEW ARTICLE for Cardiac Arrest A Systematic Review and Meta-analysis KoKo Aung, MD, MPH; Thwe Htay, MD Background: The current guidelines for cardiopulmonary resuscitation recommend vasopressin as an
More informationANZCOR Guideline 12.4 Medications and Fluids in Paediatric Advanced Life Support
ANZCOR Guideline 12. Medications and Fluids in Paediatric Advanced Life Support Who does this guideline apply to? This guideline applies to infants and children. Summary Who is the audience for this guideline?
More informationQuiz 4 Arrhythmias summary statistics and question answers
1 Quiz 4 Arrhythmias summary statistics and question answers The correct answers to questions are indicated by *. All students were awarded 2 points for question #2 due to no appropriate responses for
More informationJeopardy Topics: THE CLOT STOPS HERE (anticoagulants) SUGAR, SUGAR, HOW D YOU GET SO HIGH (insulins)
Jeopardy Topics: THE CLOT STOPS HERE (anticoagulants) SUGAR, SUGAR, HOW D YOU GET SO HIGH (insulins) I HEAR YA KNOCKING BUT YOU CAN T COME IN (electrolytes) TAKE MY BREATH AWAY (Opiates-morphine) OUT WITH
More informationVasopressors. Judith Hellman, M.D. Associate Professor Anesthesia and Perioperative Care University of California, San Francisco
Vasopressors Judith Hellman, M.D. Associate Professor Anesthesia and Perioperative Care University of California, San Francisco Overview Define shock states Review drugs commonly used to treat hypotension
More informationSystolic Blood Pressure Intervention Trial (SPRINT) Principal Results
Systolic Blood Pressure Intervention Trial (SPRINT) Principal Results Paul K. Whelton, MB, MD, MSc Chair, SPRINT Steering Committee Tulane University School of Public Health and Tropical Medicine, and
More informationACLS Provider Manual Comparison Sheet Based on 2010 AHA Guidelines for CPR and ECC. BLS Changes
ACLS Provider Manual Comparison Sheet Based on 2010 AHA Guidelines for CPR and ECC CPR Chest compressions, Airway, Breathing (C-A-B) BLS Changes New Old Rationale New science indicates the following order:
More informationACLS Cardiac Arrest Algorithm Neumar, R. W. et al. Circulation 2010;122:S729-S767
ACLS Cardiac Arrest Algorithm Neumar, R. W. et al. Circulation 2010;122:S729-S767 Copyright 2010 American Heart Association ACLS Cardiac Arrest Circular Algorithm Neumar, R. W. et al. Circulation 2010;122:S729-S767
More informationUtstein-style guidelines for uniform reporting of laboratory CPR research.
Resuscitation 33 (1996) 69 84 Utstein-style guidelines for uniform reporting of laboratory CPR research. A Statement for Healthcare Professionals from a Task Force of the American Heart Association, the
More informationVASOPRESSORS are believed to improve the outcome
Acta Anaesthesiol Scand 2006; 50: 1125 1130 Printed in Singapore. All rights reserved # 2006 The Authors Journal compilation # 2006 Acta Anaesthesiol Scand ACTA ANAESTHESIOLOGICA SCANDINAVICA doi: 10.1111/j.1399-6576.2006.01141.x
More informationThe management of cardiac arrest
CHAPTER 6 The management of cardiac arrest LEARNING OBJECTIVES In this chapter you will learn: How to assess the cardiac arrest rhythm and perform advanced life support 6.1. INTRODUCTION Cardiac arrest
More informationIt is recommended that the reader review each medical directive presented in this presentation along with the actual PCP Core medical directive.
It is recommended that the reader review each medical directive presented in this presentation along with the actual PCP Core medical directive. This presentation will highlight the changes and any new
More informationSection Four: Pulmonary Artery Waveform Interpretation
Section Four: Pulmonary Artery Waveform Interpretation All hemodynamic pressures and waveforms are generated by pressure changes in the heart caused by myocardial contraction (systole) and relaxation/filling
More informationACLS Study Guide BLS Overview CAB
ACLS Study Guide The ACLS Provider exam is 50-mutiple choice questions. Passing score is 84%. Student may miss 8 questions. For students taking ACLS for the first time or renewing students with a current
More informationPediatric Pharmacotherapy A Monthly Newsletter for Health Care Professionals Children s Medical Center at the University of Virginia
Pediatric Pharmacotherapy A Monthly Newsletter for Health Care Professionals Children s Medical Center at the University of Virginia Volume 2 Number 12 December 1996 Medications for Neonatal and Pediatric
More informationCardiopulmonary arrest (CPA) is defined as cessation of
1 CE Credit Cardiopulmonary Resuscitation: Administering Fluids, Oxygen, and Drugs Amy N. Breton, CVT, VTS (ECC) Veterinary Emergency and Specialty Center of New England Waltham, Massachusetts This article
More informationNew Approaches for Prehospital Cardiac Arrest Management 2010 NCEMSF Conference
New Approaches for Prehospital Cardiac Arrest Management 2010 NCEMSF Conference Mark E. Pinchalk, MS, EMT-P Paramedic Crew Chief City of Pittsburgh EMS Out of Hospital Cardiac Arrest Poor outcomes: Arizona
More informationAll Intraosseous Sites Are Not Equal
All Intraosseous Sites Are Not Equal Clinical Data Suggests the Sternal IO Route Improves Patient Outcomes Current Guidelines, (such as AHA) indicate that Intraosseous Infusion (IO) is a rapid, safe and
More informationVasopressin and epinephrine versus epinephrine in management of patients with cardiac arrest: a meta-analysis
SIGNA VITAE 10; 5(1): - 26 ORIGINAL Vasopressin and epinephrine versus epinephrine in management of patients with cardiac arrest: a meta-analysis XIAO-LI JING DONG-PING WANG XIN LI HUI LI XIAO-XING LIAO
More informationEMBARGOED FOR RELEASE
Systems of Care and Continuous Quality Improvement Universal elements of a system of care have been identified to provide stakeholders with a common framework with which to assemble an integrated resuscitation
More informationRATE VERSUS RHYTHM CONTROL OF ATRIAL FIBRILLATION: SPECIAL CONSIDERATION IN ELDERLY. Charles Jazra
RATE VERSUS RHYTHM CONTROL OF ATRIAL FIBRILLATION: SPECIAL CONSIDERATION IN ELDERLY Charles Jazra NO CONFLICT OF INTEREST TO DECLARE Relationship Between Atrial Fibrillation and Age Prevalence, percent
More informationST. ROSE HOSPITAL EMERGENCY SERVICES THERAPEUTIC HYPOTHERMIA AFTER CARDIAC ARREST PROTOCOL PURPOSE
PURPOSE To outline the management of therapeutic hypothermia for the patient following cardiac arrest. LEVEL SUPPORTIVE DATA EFFECTS OF THERAPEUTIC HYPOTHERMIA Interdependent. Requires MD order. Cardiac
More informationAmerican Heart Association ACLS Pre-Course Self Assessment Dec., 2006. ECG Analysis. Name the following rhythms from the list below:
American Heart Association ACLS Pre-Course Self Assessment Dec., 2006 ECG Analysis This pre-test is exactly the same as the pretest on the ACLS Provider manual CD. This paper version can be completed in
More informationAltitude. Thermoregulation & Extreme Environments. The Stress of Altitude. Reduced PO 2. O 2 Transport Cascade. Oxygen loading at altitude:
Altitude Thermoregulation & Extreme Environments Reduced PO 2 The Stress of Altitude O 2 Transport Cascade Progressive change in environments oxygen pressure & various body areas Oxygen loading at altitude:
More informationEpinephrine in Resuscitation: Curse or Cure? Robert R Attaran, Gordon A Ewy Future Cardiol. 2010;6(4):473-482.
1 of 15 6/18/2014 6:46 PM Epinephrine in Resuscitation: Curse or Cure? Robert R Attaran, Gordon A Ewy Future Cardiol. 2010;6(4):473-482. www.medscape.com Abstract and Introduction Abstract The use of epinephrine
More informationResuscitation 81 (2010) 617 621. Contents lists available at ScienceDirect. Resuscitation. journal homepage: www.elsevier.com/locate/resuscitation
Resuscitation 81 (2010) 617 621 Contents lists available at ScienceDirect Resuscitation journal homepage: www.elsevier.com/locate/resuscitation Experimental paper Intra-arrest selective brain cooling improves
More informationGUIDELINE 11.5 MEDICATIONS IN ADULT CARDIAC ARREST
AUSTRALIAN RESUSCITATION COUNCIL GUIDELINE 11.5 MEDICATIONS IN ADULT CARDIAC ARREST While the listed drugs have theoretical benefits in selected situations, no medication has been shown to improve long-term
More informationRESPONDING TO ANESTHETIC COMPLICATIONS
RESPONDING TO ANESTHETIC COMPLICATIONS General anesthesia poses minimal risk to most patients when performed by a capable anesthetist using appropriate protocols and proper monitoring. However, it is vitally
More informationEdwards FloTrac Sensor & Edwards Vigileo Monitor. Understanding Stroke Volume Variation and Its Clinical Application
Edwards FloTrac Sensor & Edwards Vigileo Monitor Understanding Stroke Volume Variation and Its Clinical Application 1 Topics System Configuration Pulsus Paradoxes Reversed Pulsus Paradoxus What is Stroke
More informationROC CONTINUOUS CHEST COMPRESSIONS STUDY (CCC): MEDICAL CARDIAC ARREST MEDICAL DIRECTIVE
ROC CONTINUOUS CHEST COMPRESSIONS STUDY (CCC): MEDICAL CARDIAC ARREST MEDICAL DIRECTIVE An Advanced Care Paramedic will provide the treatment based on the randomization scheme and as prescribed in this
More informationLow-gradient severe aortic stenosis with normal LVEF: A disturbing clinical entity
Low-gradient severe aortic stenosis with normal LVEF: A disturbing clinical entity Jean-Luc MONIN, MD, PhD Henri Mondor University Hospital Créteil, FRANCE Disclosures : None 77-year-old woman, mild dyspnea
More informationBier Block (Intravenous Regional Anesthesia)
Bier Block (Intravenous Regional Anesthesia) History August Bier introduced this block in 1908. Early methods included the use of two separate tourniquets and procaine was the local anesthetic of choice.
More informationScience Driving the Future of Resuscitation: ACLS
Paris Hotel and Casino Las Vegas, Nevada Science Driving the Future of Resuscitation: ACLS Joseph P. Ornato, MD, FACP, FACC, FACEP Professor & Chairman, Dept. of Emergency Medicine Professor, Internal
More informationManagement of the Patient with Aortic Stenosis undergoing Non-cardiac Surgery
Management of the Patient with Aortic Stenosis undergoing Non-cardiac Surgery Srinivasan Rajagopal M.D. Assistant Professor Division of Cardiothoracic Anesthesia Objectives Describe the pathophysiology
More informationREFERRAL HOSPITAL. The Importance of Door In Door Out Time DIDO
REFERRAL HOSPITAL The Importance of Door In Door Out Time DIDO Time to Treatment is critical for STEMI patients For patients with ST-segment elevation myocardial infarction (STEMI), percutaneous coronary
More informationResuscitation of the Pediatric Patient with Pulmonary Hypertension
Resuscitation of the Pediatric Patient with Pulmonary Hypertension David L. Wessel, MD Senior Vice President IKARIA Distinguished Professor of Critical Care Medicine Children s National Medical Center
More information1p36 and the Heart. John Lynn Jefferies, MD, MPH, FACC, FAHA
1p36 and the Heart John Lynn Jefferies, MD, MPH, FACC, FAHA Director, Advanced Heart Failure and Cardiomyopathy Services Associate Professor, Pediatric Cardiology and Adult Cardiovascular Diseases Associate
More informationPresent : PGY 王 淳 峻 Supervisor: F1 王 德 皓 991109
Present : PGY 王 淳 峻 Supervisor: F1 王 德 皓 991109 Interventions to prevent cardiac arrest + Airway management + Ventilation support + Treatment of bradyarrhythmias & Tachyarrhythmias Treat cardiac arrest
More informationMilwaukee School of Engineering Gerrits@msoe.edu. Case Study: Factors that Affect Blood Pressure Instructor Version
Case Study: Factors that Affect Blood Pressure Instructor Version Goal This activity (case study and its associated questions) is designed to be a student-centered learning activity relating to the factors
More informationOfficial Online ACLS Exam
\ Official Online ACLS Exam Please fill out this form before you take the exam. Name : Email : Phone : 1. Hypovolemia initially produces which arrhythmia? A. PEA B. Sinus tachycardia C. Symptomatic bradyarrhythmia
More informationDr Kenneth Tan. MBBS MMed(Anaes) MRCP(UK) EDIC FCCP Anesthesia and Intensive Care Services Mount Elizabeth Hospital
Dr Kenneth Tan MBBS MMed(Anaes) MRCP(UK) EDIC FCCP Anesthesia and Intensive Care Services Mount Elizabeth Hospital Adrenergic receptor agnoists Adrenaline Noradernaline Dobutamine Dopamine Phosphodiesterase
More informationPHYSICIAN ORDERS / PROGRESS NOTES
PHYSICIAN / PROGRESS NOTES Drs Joseph Thibodeau and Louis Violi Created: 4/10 - Next Review: 4/10 Page 1 of 5 Initiation Phase: Emergency Department Notify Interventional Cardiology and Cath Lab immediately
More information