Audience Survey
• Who has been certified in ACLS in last 3 years?
• Who was certified before then?
• Anyone ever give bystander CPR or CPR in the field?
• When was last time you participated in a Code Blue that had a really good outcome?
Audience Opinions
• Who thinks that CPR works?
• Can you actually save anyone?
• Would you initiate CPR as a bystander?
• Who has talked to Ann Lockhart or Elise Lewis about their experience on the reservoir run?
Grim Statistics for Code Blue
• Return of spontaneous circulation (ROSC) of about 40% - 60%
• Survival to hospital discharge of at most 15%
• Long term (3 year) survival ~40% OF the 15% that are discharged
• Long-term survival after successful in hospital cardiac arrest resuscitation American Heart Journal - Volume 153, Issue 5 (May 2007)
• Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of "limited" resuscitations. - Dumot JA - Arch Intern Med - 23-JUL-2001; 161(14): 1751-8 (From NIH/NLM MEDLINE)
38 YO Asian Male Homicide Detective
• Rides road bike total of 250 miles during week of 10/5/08
• Goes for easy 3 mile training run w/ other officers 10/15/08
• Stretches post run; reaching for the sky is the last thing he remembers until waking in the ER
What Happened While He was Asleep?
• Collapsed forward, striking head and face
• Pale, unresponsive, pulseless
• Companion officers start EXCELLENT CPR
• SRFD on scene in less than 3 minutes, defibrillator pads placed, rhythm checked…
V-Fib Arrest
• Shock w/ 120 Joules• Continue EXCELLENT CPR (How do we know it was excellent?)
• Check pulse, check rhythm – carotid pulse present, sinus rhythm
• Transport to Santa Rosa Memorial Hospital
• In ER trauma bay, patient becomes alert, speaks coherently, and complains of being very sore
Epilogue
• Patient goes to cardiac catheter where he is diagnosed with severe 3 vessel disease
• Undergoes 3 Vessel CABG
• EP study demonstrates need for implantable defibrillator
• His friends take CPR and get their own cholesterol checked
Excellent CPR: Hard and Fast
• New ratio is 30:2
• Chest compressions are more important than rescue breaths
• Compressions delivered at 100/minute (staying alive, staying alive, ah, ah, ah…)
• Ventilations 8-10/minute – slower than you think
Rhythm Check
• There is only one question…
• To shock, or not to shock
• V-Fib or pulseless V-Tach • SHOCK
• PEA or Asystole
• MEDS AND CONTINUED CPR
NEW: KEEP DOING CPR!
• After delivering a shock, resume CPR for 2 minutes before checking rhythm again
• Simultaneously check for pulse
• Resume CPR while defibrillator charges, if need to shock again
Drugs Work
• NO MORE ET Tube administration
• IV access or IO access as soon as possible
• Epinephrine/Vasopressin Q3-5 minutes
• Amiodarone after Epi/Vasopressin; Lidocaine also OK, but now out of favor and not in field protocols
Vasopressin
Indicated for V-Fib, V-Tach, PEA, Asystole;
Give ONLY ONCE
• 40 Units IV/IO instead of 1st or 2nd dose of Epinephrine
• NOT for responsive (talking) patients with known CAD
Epinephrine
First line drug for ALL pulseless rhythms
• 10 ml of 1:10,000 solution -- bolus
• 1 mg in 500 ml of NaCl or D5W @ 1microgram/min, titrate to effect
Amiodarone
Give for V-Fib or pulseless V-Tach
• 1st dose: 300 mg IV/IO
• 2nd dose: 150 mg IV/IO
• Infuse: 0.5 mg/min x 18 hours
Atropine
Symptomatic bradycardia or SLOW PEA
• PEA, Asystole: 1mg IV/IO Q3-5 min
• Bradycardia: 0.5mg IV/IOQ3-5 min, PRN
• Note that dose < 0.5mg can cause paradoxical bradycardia
72 YO Caucasian Family Doctor
• Swimming, per his usual at the local pool
• Not feeling up to par, decides he should get out
• Wakes up in ICU
• What happened?
By stander CPR
• Oral surgeon swimming in same lane starts poor quality CPR
• 2 ER nurses, having breakfast @ poolside shove surgeon out of way and start excellent CPR
• Paramedics arrive, and deliver 2 shocks in field between continued CPR, establishing a line and intubating
• Transport to ER – CPR continuing
ER Code Blue
• On arrival to ER, rhythm remains VFib
• Shock in ER and Amiodarone bolus
• Rhythm converts to sinus
• Transferred to ICU
• Implantable defibrillator placed
Top Related