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What is the mc initial rhythm in witnessed sudden cardiac arrest?
- VF or rapid pulseless VT.
- When VF is present, heart quivers and does not pump blood.
- Only effective treatment if defib
- Probability of success decreases over time. 7-10% each min. 3-4 % with CPR
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What are the players?
1. Defib (shock)
- 2. Vasopressors
- Epinephrine
- Vasopressin
- 3. Antiarrhythmic
- Amiodarone
- Lidocaine
- Magnesium sulfate
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Patient alarms sounds
Patient unresponsive and you see VF on monitor.
Pulse check: none
What do you do?
Start CPR
- Get Pads ready
- Defib after 2 min of CPR
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What is the energy dose for defibrillation?
- Monophasic -> 360 J
- Biphasic -> 200J
- Biphasic Truncal -> 120 J
When in doubt -> 200 J
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Subsequent shocks should be?
Same or higher Joules
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What should you do immediately before shock?
After shock?
Say Im clear, your clear, everyone clear!
- After shock, immediately resume CPR with check compressions.
- Not recommended to check rhythm until after 2 min of CPR after shock.
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After one shock and one 2 min of CPR, rhythm shows VF still.
What do you do next?
- Repeat SHOCK
- Give Vasopressor
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Which vasopressor do you give and how much?
Give Epinephrine 1 mg IV push, q 3 min
OR Vasopressin 40 U IV push instead of epi 1st or 2nd dose
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Why do we use vasopressors?
Vasopressors optimizez cardiac output and blood pressure
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EPI dose and MOA
Epi for VF or pulseless VT dose
1 mg IV push, q 3 min
- EPi has an alpha adrenergic effects
- causes vasoconstriction which
- *increases cerebral blood flow
- * coronary blood flow.
- *increase mean arterial pressure
- *increases aortic diastolic pressure
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Vasopressin dose and MOA
- In VF/pulseless TV
- Vasopressin can be used instead of first or second dose of EPI
- Dose 40 Units IV once
- Vasopressin has nonadrenergic peripheral vasoconstrictor of
- coronary and renal vessels
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patient now recieved
shocks, cpr, shock & Epi, cpr...
still in VF now what?
SHock again!, CPR
Consider antiarrhythmic drug
*Amiodarone
*OR Lidocaine
*Magnesium if Torsades.
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Amiodarone dose and MOA?
- Amiodarone 300 mg IV push
- AFTER 3 min
- 150 mg IV
- Ami affects NA, K, Ca channels
- Has alpha and beta adrenergic properties.
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Lidocaine dose?
- Lidocaine can be used INSTEAD OF AMIODARONE
- Dose 1-1.5 mg/kg IV
- After 5 min
- Repeat 1/2 dose
- 0.5-0.75 mg/kg dose IV
up to 3 doses
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Magnesium dose and indications
Magnesium is indicated for Torsades.
Dose 1-2 mg IV in 10 ml D5W over 5-20 min
suspect Low mag in ETOH, Malnutrition.
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VF or Pulseless VT in Hypothermic Pts
- Hypothermic pts < 30 C or < 86 F
- give one shock, hold meds until pt is warm and core temp is > 86 F
- Hypothermic heart does not respond to medications, defib or pacemaker.
- Drugs can accumulate and cause toxic levels
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VF, Pulseless VT treatment sequence
START CPR
- Prepare pads, deliver 1 Shock
- Resume CPR for 2 min
- Check Rhythm
Shock, CPR, Vasopressor
Shock, CPR, consider Antiarrythmic
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What meds do you use for postresuscitation maintenance therapy for recurrent VF/VT
Amiodarone or Lidocaine
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What is the purpose of defib?
- Defibrillation does not restart the heart.
- Defib stuns the heart and briefly terminates all electrical activity, esp VT/VF.
- If heart is viable, its normal pacemaker may resume electrical activity.
- In first minutes of Defib, any spontaneous rhythm is slow and does not create a pulse or perfusion.
- CPR is needed. This is why we resume immediate CPR after shock.
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Outside hospital,
when do you use AED
- No response
- NO breathing
- No pulse!
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At what age do you use child pads
< 8
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