.

     

     

    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:
    1. 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
    2. 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.

     

    • 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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