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CARDIOPULMONARY RESUSCITATION & EMERGENCY CARDIOVASCULAR CARE

DECEMBER 2005 GUIDELINES

Classification of Recommendations and Level of Evidence


CLASS CLASS CLASS

Procedure/Rx/Diagnostic

I: Benefit>>>Risk IIa: Benefit>>Risk IIb: Benefit=Risk

Test should be done

Procedure/Rx/Diagnostic

Test reasonable to perform

Procedure/Rx/Diagnostic may be considered Optional vs expert recommendation

CLASS

Procedure/Rx/Diagnostic

III: Risk>Benefit

should not be performed/harmful

New Recommendations
2

breaths chest compressions All breaths (mouth-mouth, mouth-bag, bag-mask) given over 1 sec see chest rise Longer uninterrupted chest compression Compression:Breath (30:2) Push hard and push fast (100/minute) 2 min of compression before rhythm/pulse check in pulseless arrest Pulseless VF/VT: 1 shock (instead of stacked)

CPR
Compress

nipple line

at the center of the chest at the

Compress

the chest approximately 1.5-2 inches using heel of hands

Automated Electrical Defibrillators(AED), Defibrillation, Cardioversion, Pacing

Electrical Therapies

Immediate
No

CPR until defibrillator available 1-Shock vs 3-shock sequence


studies humans/animals comparing the two Animal studies: long interruptions in CPR assoc w/ post-resuscitation myocardial dysfunction and decr. survival RCT: interruptions in CPR assoc w/ decr. probability of conversion of VF to another rhythm 3-Shock: 37 sec delay before 1st compression 1-Shock: efficacy of conversion >90% (biphasic defibrillators)

Monophasic vs Biphasic Defibrillators


1st-shock

efficacy of monophasic < 1st-shock efficacy of biphasic Goal: delivery of current through chest to the heart to depolarize myocardial cells and eliminate VF/VT Monophasic:
Biphasic

delivers current of one polarity 1-shock 360J

<200J as safe and w/ higher efficacy than higher voltage in monophasic 120J, 150J, 200J

AED
Only useful for shockable rhythms If implantable medical device (pacemaker,

place 1 inch away Do Not place on transdermal medication devicesburns, decrease energy to heart Individual wet/diaphoreticdry Decreasing impedance
Shave

AICD)

Arched

placement of AED in O2-rich environment can spark fires

chest hair Conductive gel

Synchronized Cardioversion
Shock

delivery timed with QRS complex Indicated for Rx of unstable tachyarrhythmias associated with organized QRS complex and a perfusing rhythm Rx unstable SVT
Reentry Atrial

Fibrillation mono=100-200J, bi=100-120J Atrial flutter mono=50-100J, bi=100-120J Unstable monomorphic VT 100J, bi=100-120J

NOT

effective

Junctional

tachycardia Ectopic/multifocal-atrial tachycardia (automatic focus) Shocks to automatic focus can further increase HR

Pacing
Symptomatic

bradycardia

RCT:

Asytolic patients and pacing


improvent in survivalClass III

No

Medication for Arrest Rhythms


VASOPRESSORS No controlled trials demonstrating increased rate of neurologically intact survival to hospital discharge

Evidence that Vasopressor agents favors initial ROSC

EPINEPHRINE
Alpha-adrenergic

vasoconstrictor properties increases coronary and CPP during CPR Beta-adrenergic properties controversial as they may increase myocardial work and reduce subendocardial perfusion 1mg dose vs High dose NSS in 8-RCT 1mg dose Q 3-5 min CLASS IIB

VASOPRESSIN
Non-adrenergic Coronary

peripheral vasoconstrictor

and renal vasoconstrictor

Meta-analysis

of 5-RCT NSS between EPI and VP for ROSC, 1-hour survival, 24-hrsurvival, or survival to hospital d/c Dose: 40 Units

ATROPINE
Reverses

SVR, BP

the cholinergic mediated decrease in HR,

No

prospective controlled studies supporting its use in Asystole/ PEA

Retrospective

review: intubated pts w/ refractory asystole (in the field) increased survival to hospital admission Caution in ACS/AMI as may Incr HR and worsen ischemia May not be effective in cardiac transplant patients as the transplanted heart lacks vagal innervation Dose: 1mg Q 3-5 min (max 3mg)

Amiodarone
Affects

Na, K, Ca-channels, alpha and betaadrenergic blocking properties (in the field): Amio vs Placebo vs Lido

RCT

Increased

survival to hospital admission (SS) Improved defibrillator response (SS)

Initial:

300mg, then 150mg


***(SS) Statistically Significant

Magnesium
Observational

studies termination of

Torsades

1-2g

in 50-100cc D5W over 5-20min

ETT Medications

NAVEL
NALOXONE ATROPINE VASOPRESSIN EPINEPHRINE LIDOCAINE ***Dose at 2-2.5 x normal

VF/VT
Most

critical intervention during 1st min

Immediate

bystander CPR w/ min interruptions in chest compressions and Defib ASAP Class 1

1-shock

instead of 3-shocks (stacked)

PULSELESS ARREST VF/VT


1ST-shock (M=360J, B=120-200J) CPR X 2 minutes 1-shock Epi 1mg Q 3-5min OR Vasopressin 40U 1-shock Amiodarone 300mg (then 150) OR lidocaine 1-1.5mg/kg x 1 (then 0.5 - 0.75 mg/kg x 2) Magnesium 2 gms IV for Torsades

***CPRRHYTHM CHECKSHOCK

PULSELESS ARREST
ASYSTOLE/PEA

CPR x 2 min Epi 1mg Q 3-5 min OR VP 40U CPR x 2 minutes Atropine 1 mg Q 3-5 minutes (max 3 doses) for asystole or slow PEA
***CPR: PUSH HARD , PUSH FAST
(100 COMPRESSIONS PER MINUTE )

***1 DOSE VP SUBSTITUTES 2 DOSES OF EPI

PULSELESS ELECTRICAL ACTIVITY (PEA)

PULSELESS ARREST

6 Hs
Hypovolemia Hypoxia Hydrogen ion (acidosis) Hypo-/Hyperkalemia Hypoglycemia Hypothermia

5 Ts
Toxins Tamponade Thrombosis (coronary or pulmonary) Tension PTx Trauma

Symptomatic Bradycardia
HR<60,

and inadequate for clinical condition

change in mental status, ongoing severe ischemic CP, CHF, hypotension, shock
Airway,

oxygen, EKG monitor, IV TCP (immediate in type II 2nd,3rd AVB) CLASS 1 Atropine 0.5mg (may repeat to max 3mg) Epi 2-10mcg/min OR dopa 2-10mcg/kg/min TVP Glucagon 3mg IV3mg/hr for BB/CCB overdose refractory to atropine

Tachyarrythmia
Narrow Complex
QRS<0.12

Wide Complex
QRS>0.12

Sinus Tachycardia AF/AFl AV-nodal reentry Atrial Tachycardia (ectopic,reentrant) MAT Junctional tachycardia

VT SVT with aberrancy

Narrow Complex
Regular
Vagal Maneuver Adenosine 6, 12, 12 **If converts:reentrant SVT If not converted: CCB, BB, Amio (EF<40%) **Afl, Ectopic A.tach, J,tach

Irregular
CCB, BB, Amio (EF<40%) **AF, Afl, MAT

Wide Complex
VT

or Uncertain rhythm
Amiodarone

150mg Synchronized cardioversion


AF+WPW

(pre-excited AF)

Amiodarone

150mg AVOID: adenosine, Digoxin, Diltiazem, Verapamil

Review
Pulseless
CPR,

VF/VT

120J, CPREPI/VPCPR,AirwayAmio 300 CPR X 2 min then shock

Asystole/PEA
Epi,

Atropine

Symptomatic
TCP,

Bradycardia

Atropine, Epi/Dopa, TCP Adenosine, CCB/BB/Amio

Narrow

Complex Tachycardia:

Vagal,

Wide

Complex Tachycardia

Amio

58yo female with DM, HTN, found unresponsive, No Pulse

65 yo male with CODE BLUE, unresponsive and no palpable pulse

76 yo female with acute SOB and complaints of mild CP

50 yo male with HTN, DM, heroine abuse, CRI on HD found down and without palpable pulses