Table of contents
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Introduction
- Cardiac: Download ACLS Cardiac Card Here & Printer-Friendly .doc Version
- Stroke: Download ACLS Stroke Card Here & Printer-Friendly .doc Version
Vasoactive Medications
-
Drug Dose Effect Notes Epinephrine 1mg (10mL of a 1:10,000 solution)
as a bolus IV/IO q3-5min
Endotracheal: not recommended
(poor absorption)
B-receptor agonist in low doses
a-receptor agonist in high doses
Vasopressin 40 units IV/IO as a single dose - Non-adrenergic vasoconstriction
- Unwanted effect: coronary
vasoconstriction***
- Can replace 1st or 2nd dose of epi
- No survival benefit when
vasopressing substituted for epi
Antiarrhythmic Medications
-
Drug Dose Effect Notes Amiodarone Initial Dose: 300mg IV/IO
Second dose 150mg if needed
- Hypotension
Bradycardia
- Recommended for V-Fib and pulseless V-Tach refractory
to defibrillation and vasoactive medications
Lidocaine Initial: 1-1.5 mg/kg IV/IO
Then: 0.5-0.75 mg/kg q5-10m
to max of 3 doses or 3mg/kg
- Traditionally used (ischemic myocardium acidic activates
lidocaine).
- Amio produces better short-term survival in study
Lidocaine now recommended as 2nd line.
Magnesium 1-2 grams IV/IO over 5min - For polymorphic VT ("Torsades de pointes") Atropine 1mg IV/IO q3-5min
(Max: 3mg = complete vagal
blockade)
- Anticholinergic - Adjunct for asystole or slow-rate PEA
Post-Arrest Care
Therapeutic Hypothermia
- Generally avoid fever (suppress with acetaminophen)
-
Therapeutic Hypothermia after Cardiac Arrest Guidelines:
Eligible Patients:
- Out-of-hospital cardiac arrest due to V-Fib or V-Tach who remain comatose after ROSC
Inclusion Criteria
- Cardiac arrest is cardiac in origin
- Body temperature is not reduced
- Patient is hemodynamically stable
- Patient is intubated on a ventilator
Methodology
1. Begin cooling 1-2hrs after CPR
2. Cooling blanket to achieve T of 32-34°C (89.6-93.2°F)
3. Use sedation and neuromuscular blockade to avoid shivering
4. Watch for hyperkalemia and hyperglycemia during hypothermia
5. Maintain hypothermia for 12-24hrs then allow passive rewarming
Sources: Bernard et al NEJM 2002 & "The Little ICU Book" Marino 2008.
- Maintain temp no less than 12h and no more than 24hrs.
- Suppress shivering with neuromuscular blockade (i.e. atracurium)
- Watch for hyperkalemia and hyperglycemia with cooling!!!
- Hyperglycemia = poor neurologic outcome
Predicting Neurologic Recovery
- Challenging, but the following are factors:
- Duration of Coma
- If > 4-6 hrs = poor recovery (<15% full recovery rate)
- if > 24 hrs = 10% chance of satisfactory neurologic recovery
- GCS < 5 points on 3rd day = Little or no chance of neurologic recovery
- Other Prognostic Signs
- Review of 11 studies of pts who did not immediately awaken post-CPR found 4 clinical signs independently predict death or poor neuro recovery after cardiac arrest:
- A.) No corneal reflex
- B.) No pupillary reflex
- C.) No withdrawal to pain
- D.) No motor response
- Presence of any of these signs at 24hrs post-arrest = poor prognosis for neurologic recovery.
- Review of 11 studies of pts who did not immediately awaken post-CPR found 4 clinical signs independently predict death or poor neuro recovery after cardiac arrest:
- Note on pupils
- neuromuscular blockade does not affect pupil size/reactivity
- Systemic atropine causes pupil dilation (but remain reactive)
- High-Dose dopamine causes fixed dilated pupils
- If pupils remain non-reactive for > 6-8hrs after resuscitation from an arrest, cahnces of satisfactory neurologic recovery are very poor.
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