Professional Documents
Culture Documents
Procedure/Rx/Diagnostic
Procedure/Rx/Diagnostic
CLASS
Procedure/Rx/Diagnostic
III: Risk>Benefit
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
Compress
Electrical Therapies
Immediate
No
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
<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
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:
No
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
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
No
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
Initial:
Magnesium
Observational
studies termination of
Torsades
1-2g
ETT Medications
NAVEL
NALOXONE ATROPINE VASOPRESSIN EPINEPHRINE LIDOCAINE ***Dose at 2-2.5 x normal
VF/VT
Most
Immediate
bystander CPR w/ min interruptions in chest compressions and Defib ASAP Class 1
1-shock
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 )
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,
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
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
(pre-excited AF)
Amiodarone
Review
Pulseless
CPR,
VF/VT
Asystole/PEA
Epi,
Atropine
Symptomatic
TCP,
Bradycardia
Narrow
Complex Tachycardia:
Vagal,
Wide
Complex Tachycardia
Amio
50 yo male with HTN, DM, heroine abuse, CRI on HD found down and without palpable pulses