mega code
TRANSCRIPT
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Sense
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React
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Result !!
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TODAY
Review the latest changes in BLS & ACLS
Review of most common & important EKG Rhythms.
ACLS pulseless algorithm
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Responsiveness
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Primary A,B,C,D
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Primary A,B,C,D
2005 International Consensus Conference.Circulation 2005;112:III-17
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Secondary A,B,C,D
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Secondary A,B,C,D
3
121
2
3
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Secondary A,B,C,D
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1. Primary confirmation
1. Visualizes ETT goes through the vocal cords
2. Observes vapors in the tube
3. Chest rise
4. 5 point auscultation of the chest
Secondary A,B,C,D
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Secondary A,B,C,D
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Secondary A,B,C,D
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Secondary A,B,C,D
– Circulation
1. Establish IV access
2. Identify rhythm monitor
3. Administer drugs
4. “appropriate for rhythm and condition”
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Ewy, G. A. Circulation 2005;111:2134-2142
Simultaneous recording of aortic diastolic (red) and right atrial (yellow) pressures during CPR in
which 2 ventilations are delivered within 4-second time period
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Secondary A,B,C,D
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Secondary A,B,C,D
– Deferential Diagnosis
– search for and treat identified
reversible causes
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Secondary A,B,C,D
6 H’s
– Hypovolemia
– Hypoxia
– Hydrogen Ions “acidemia”
– Hyperkalemia / Hypokalemia
– Hypothermia
– Hypoglycemia
6 T’s
– Tablets
– Thrombosis “coronary”
– Thrombosis “Pulmonary”
– Tension pneumothorax
– Tamponade, Cardiac
– Trauma
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– Checking the heart rhythm
– Checking the pulse
– inserting airway devices
– administration of drugs should be done
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Asystole
– “Flat line” protocol:
1. Check leads attachment.
2. Check leads selection
3. Power on/off
4. Check the gain
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VF pulseless VT
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EKG review
Three questions:
1. Rate
2. QRS narrow or wide
3. P wave & PR interval
1. Tachy vs. Brady
100 < rate < 60
1. Supraventricular vs. ventricular
2. Source of rhythm & blocks
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Medications
1. Why? (Actions)
2. When? (Indications)
3. How? (Dose)
4. Watch Out! (Precautions)
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What is the most important medication in the cardiac arrest?
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O2
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How to give the medicationduring CRP?
• I.V.– Fast I.V. Bolus.
– 10 cc N.S. flush.
– Raise the arm.
– Use central venous access if it available.
• E.T.T– 2-3 times the I.V. dose
– Diluted 10cc N.S.
– 3-4 ambo-bag “to
diffuse the medication”
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Which Meds can be given
through E.T.T?
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NAVEL
Naloxon Atropine Vasopressin Epinephrine Lidocaine
Which Meds can be given
through E.T.T?
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Epinephrine
• Action : α & β – adrenergic agonist activity
• Indication: all Pulseless rhythms.
• Dose:• initial dose 1mg ( 10mL of 1:10 000 solution )
• Additional doses of 1mg every 3- 5 min
• No maximum dose.
• Precautions: • PVC with digitalis.
• Hypertension
• Myocardial ischemia
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Vasopressin
• Survival higher in patients who had higher endogenous vasopressin 1,2
• Action :
• Vasoconstriction by direct stimulation of the smooth muscle V1 receptor.
• Combination with epinephrine resulted in decreased cerebral perfusion 3
• increase coronary perfusion and cerebral oxygen delivery during CPR 4
• Has no β – adrenergic activity.
• Indication: all Pulseless rhythms.
• Dose:
– Start with 40 units I.V. once.
– Don’t combine with epinephrine
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Vasopressin & Epinephrine
no statistically significant differences between
vasopressin and epinephrinefor death within 24 hrs or death before hospital discharge after a
successful CPR.
• There is thus insufficient evidence to support or refute the use of vasopressin as an alternative to or in combination with epinephrine in any cardiac arrest rhythm.
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Atropine
– Action : vagolytic action “SA and AV node”
– Indication: asystole & PEA with rhythm < 60/min .
– Dose:
– initial dose 1 mg
– Additional doses every 3-5 min
– max dose 3 mg/Kg
– Precautions:
– Myocardial ischemia
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Amiodarone
– Action : Na+, K+, Ca++ channel blocker and α & β Blocker.
– Indication: shock refractory VF/ Pulseless VT.
– Dose:– initial dose 300 mg bolus
– Additional doses of 150 mg/kg
– Infusion dose of – 1 mg/min for 6 Hr ( 360 mg ) then
– 0.5 mg/min for 18 Hr ( 540 mg )
– Maximum dose of 2.2 Gram / 24 Hr
– Precautions: – Prolonged QT.
– Hypotension
– Negative Inotrope
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Lidocaine
– Action : suppress ventricular arrhythmia, ectopy and prolong
the refractory period.
– Indication: shock refractory VF/ Pulseless VT.
– Dose:
– initial dose 1-1.5 mg/Kg
– Additional doses of 0.5 – 0.75 mg/kg
– max dose 3 mg/Kg
– Infusion dose of 1-4 mg/min
– Precautions:
– Decreased LVH.
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Magnesium sulfate
• Indication: hypomagnesaemia & Torsades de pointes.
• Dose:
• initial dose 1-2 gram iv push over 2 min
• Infusion dose of 1 gram/hr
• Precautions:
• Hypotension.
• Renal failure.
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Sodium bicarbonate
• Indications
– Pre-existing metabolic acidosis,
– ↑ K
– Prolonged arrest > 10 min
• Dose:
– 1 mEq / Kg
• Precautions:
– ↑ Na / Hyperosmolality
– Metabolic alkalosis
– Unfavorable shift of O2-Hb dissociation curve
• Contraindication
– hypoxic lactic acidosis
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Medication 2005 changes
Epinephrine •No change
Vasopressin •All pulseless rhythms
•Can be used in E.T.T
Atropine •Maximum dose 3 mg
Amiodarone •No changes
Lidocaine •No changes
Medications
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References
• Aung K, Htay T. Vasopressin for cardiac arrest: a systematic review and meta-analysis. Arch Intern Med 2005:17-24
• 2005 International Consensus Conference.Circulation 2005;112:III-29
• Linder KH, Strohmenger HU, Ensinger H, Hetzel WD, Ahnefeld FW, Georgieff M, Stress hormone response during and after cardiopulmonary resuscitation. Anesthesiology 1992;77:662-668
• Linder KH, Haak T, Keller A, Bothner U, Lurie KG, Release of endogenous vasopressors during and after cardiopulmonary resuscitation. Heart 1996;75:145-150
• Wenzel V, Linder KH, Augenstein S, Prengel AW, Strohmenger HU, Vasopressin combined with epinephrine decreases cerebral perfusion compared with vasopressin alone during cardiopulmonary resuscitation in pigs. Stroke. 1998;29:1462-1467: discussion 1467-1468.
• Babar SI, Berg RA, Hilwig RW, Kern KB, Ewy GA Vasopressin versus epinephrine during CPR: a randomized swine outcome study. Resuscitation 1999; 185-192
• Linder KH, Dricks B, Strohmenger HU, Prengel AW, Lindner IM, Lurie KG, Randomized comparison of epinephrine and vasopressin in patients with out of hospital VF. Lancet. 1997; 349: 535-537
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References
• Kudenchuk PJet al. Amiodarone for resuscitation after out-of-hospital
cardiac arrest due to ventricular fibrillation. N Engl J Med. 1999:871-878
• Dorian P et al. Amiodarone as compared with lidocaine for shock-resistant
ventricular fibrillation. N Engl J Med 2002:884-90
• 2005 International Consensus Conference.Circulation 2005;112:III-17
• Paul Dorian, et al. NEJM 2002 Amiodarone as Compared with Lidocaine for
Shock-Resistant Ventricular Fibrillation
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ACLS Pulseless Arrest Algorithm
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Primary A,B,C,D
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Primary A,B,C,D
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Primary A,B,C,D
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Primary A,B,C,D
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Secondary A,B,C,D
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Secondary A,B,C,D
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Secondary A,B,C,D
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Secondary A,B,C,D
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Secondary A,B,C,D
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Secondary A,B,C,D
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• “Flat line” protocol:– Check leads attachment.
– Check leads selection
– Power on/off
– Check the gain
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