Defibrillation and ACLS Drug Therapy

Prepared and presented by

Marc Imhotep Cray, M.D.

ACLS CE Part III of III

http://en.wikipedia.org/wiki/Defibrillation

Defibrillation

•Defibrillation is a common treatment for life-threatening cardiac dysrhythmias, ventricular fibrillation and pulseless ventricular tachycardia •Defibrillation consists of delivering a therapeutic dose of electrical energy to the heart with a device called a defibrillator •External depolarization of the heart to stop Vfib or Vtach that has not responded to other maneuvers

Defibrillation

• Know your AED*

• Universal steps:

1. Power ON

2. Attach electrode pads

3. Analyze the rhythm

4. Shock (if advised)

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*Automated External Defibrillator

Automated External Defibrillator

Defibrillation

• Most frequent initial rhythm in witnessed sudden cardiac arrest is ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) which rapidly deteriorates into VF

• The only effective treatment for VF is electrical defibrillation

• Probability of successful defibrillation diminishes rapidly over time

• VF rapidly converts to asystole if not treated

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Early Defibrillation = Increased Survival

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• Outcomes of Rapid Defibrillation by Security Officers after Cardiac Arrest in Casinos

• NEJM Vol 343 (17) October 26, 2000

• Used AEDs on 105 patients with Ventricular Fibrillation

• 53% survived to discharge (back to casino)

• Previously, less than 5% survive

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Also see: Use of Automated External Defibrillators by a U.S. Airline Page LA et al. N Engl J Med 2000; 343:1210-1216

Example of deploying AEDs in a highly populated and

monitored environment…Still debates about cost effectiveness

Do AEDs work?

An AED at a railway station in Japan. The AED box has information on how to use it in Japanese, English, Chinese and Korean,

and station staff are trained to use it. http://en.wikipedia.org/wiki/File:AED_Oim

achi_06z1399sv.jpg

Public-Access Defibrillation and Survival after Out-of-Hospital Cardiac Arrest

http://www.nejm.org/doi/full/10.1056/NEJMoa040566

• Community based trial of AED deployment and layperson training.

• 30 in AED group versus 15 survivors in CPR only group to hospital discharge

• Average age of survivor - 69.8 years

• Study cost - $9.5 million

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Study Conclusions “Training and equipping volunteers to attempt early defibrillation within a structured response system can increase the number of survivors to hospital discharge after out-of-hospital cardiac arrest in public locations. Trained

laypersons can use AEDs safely and effectively.”

Defibrillation Procedure

• Position paddles

• “Clear” the patient

• Shock and then resume CPR for 5 cycles then re-analyze after each shock

• Prepare drug therapy

– Next slides

ACLS Drug Therapy

N.B. Following is only a outlined capsule ACLS drugs,

for a details see

ACLS Core Drugs American Heart Association 2006, pdf

Routes of Administration

• Peripheral IV – easiest to insert during CPR

• Central IV – fast onset of action

• Intratracheally (down an ET tube)

• Intraosseous – alternative IV route in peds

Oxygen

• FIO2 100%

• Assist Ventilation

• O2 Toxicity should not be a concern during ACLS

IV Fluids

Volume Expanders

• crystalloids , e.g. Ringer’s lactate, N/S, or colloids, e.g. Albumin or Hetastarch

• TKO – D5W, N/S

Morphine Sulfate

• Drug of choice for pain

• Also decreases pre-load

• IV dose – 2-4 mg as often as every 5 minutes

• Precautions

– May cause respiratory depression

Drugs that help to Control Heart Rate & Rhythm

Lidocaine

• Indications:

– PVCs, Vtach, Vfib

– Can be toxic so no longer given prophylactically

• IV dose :

– 1-1.5 mg/kg bolus then continuous infusion of 2-4 mg/min

– Can be given down ET tube

• Signs of toxicity:

– slurred speech, seizures, altered consciousness

Amiodarone (Cordarone)

• Indications: – Like Lidocaine – Vtach, Vfib

• IV Dose: – 300 mg in 20-30 ml of N/S or D5W – Supplemental dose of 150 mg in 20-30 ml of N/S or

D5W – Followed with continuous infusion of 1 mg/min for 6

hours than .5mg/min to a maximum daily dose of 2 grams

• Contraindications: – Cardiogenic shock, profound Sinus Bradycardia, and

2nd and 3rd degree blocks that do not have a pacemaker

Procainamide (Pronestyl)

• Indications: – Like lidocaine (is usually a second choice) – Uncontrolled Afib or Atrial flutter if no signs of

heart failure • Dose :

– continuous IV infusion. Initially 20mg/min then titrated down to 1-4 mg/min

• Side effects – Hypotension – Widening of the QRS

Bretylium Tosylate (Bretylol)

• Indications:

– Same as lidocaine and procainamide (usually when condition doesn’t respond to these two)

• IV dose:

– 5-10mg/kg bolus followed by continuous infusion of 1-2 kg/min

• Side Effects:

– N & V

– Hypotension

Atropine • Indications:

– Symptomatic sinus bradycardia

– Second Degree Heart Block Mobitz I

– May be tried in asystole

– Organophosphate poisoning

• IV Dose:

– .5 – 1 mg every 3-5 minutes

– Max dose is .04mg/kg

– Can be given down ET tube

• Side Effects:

– May worsen ischemia

Isoproterenol (Isuprel)

• Indications: – Temporary stimulant prior to pacemaker

– Bradycardia refractory to atropine

– Torsades de Pointes refractory to magnesium sulfate

• IV dose: – Continuous infusion of 2-10 micrograms/ml of

infusion fluid

Adenosine • Indication:

– PSVT

• IV Dose:

– 6 mg bolus followed by 12 mg in 1-2 minutes if needed

• Side Effects:

– Flushing

– Dyspnea

– Chest Pain

– Sinus Brady

– PVCs

Verapamil

• Indications:

– Is a calcium channel blocker that may terminate PSVT (is a backup to Adenosine) as well as atrial flutter and uncontrolled atrial fib

• IV Dose:

– 2.5-5 mg over 2 minutes up to 20 mg

• Side Effects:

– Hypotension

– N & V

Magnesium

• Used for refractory Vfib or Vtach caused by hypomagnesemia and Torsades de Pointes

• Dose:

– 1-2 grams over 2 minutes

• Side Effects

– Hypotension

– Asystole!

Propranolol

• Beta blocker that may be useful for Vfib and Vtach that has not responded to other therapies

– Very useful for patients whose cardiac emergency was precipitated by hypertension

– Also used for Afib, Aflutter, & PSVT

Drugs use to Improve Cardiac Output & Blood Pressure

Epinephrine

• Because of alpha, beta-1, and beta-2 stimulation, it increases heart rate, stroke volume and blood pressure – Helps convert fine vfib to coarse Vfib – May help in asystole – Also PEA and symptomatic bradycardia

• IV Dose: – 1 mg every 3-5 minutes – Can be given down the ET tube – Can also be given intracardiac – May increase ischemia because of increased O2

demand by the heart

Vasopressin (ADH)

• Similar effects to Epinephrine without as much cardiovascular side effects!

• IV dose = 40 IU

• Can be given down ET tube

• May be better for asystole

Norepinephrine (Levarterenol)

• Similar in effect to epinephrine

• Used for severe hypotension that is NOT due to hypovolemia

• Cardiogenic shock

• Administered as a continuous infusion

– Adult rate is usually 2-12 micrograms/min

– Range is .5-1 microgram up to 30!

• Side effects:

– Like epinephrine, it may worsen ischemia

– Extravasation causes tissue necrosis

Dopamine

• Used for hypotension (not due to hypovolemia)

– Usually tried before norepinephrine

– Has alpha, beta, and dopaminergic properties

• Dopaminergic dilates renal and mesenteric arteries

• Second choice for bradycardia (after Atropine)

• IV Dose:

– 1-20 micrograms/kg

• Side effects:

– Ectopic beats

– N & V

Dobutamine

• Actions similar to Dopamine

• Used for CHF with hypotension

• IV Dose:

– 2-20 micrograms/minute

• Side effects:

– Tachycardia

– N & V

– Headache

– Tremors

Amrinone

• Similar to dobutamine

• Used for refractory CHF

• IV Dose:

– 2-15 micrograms/kg/min

• Side effects:

– May worsen ischemia

– N & V

– Thrombocytopenia

Digitalis (Digoxin)

• Slows conduction through A-V node and increases force of contraction

• Used in CHF and chronic atrial fib/flutter

• Can be given orally or IV

• Side effects:

– Arrhythmias

– N & V, diarrhea

– Agitation

Nitroglycerin

• Vasodilator that helps relieve pain from angina pectoris

• Can be given IV, sublingually, as an ointment or a slow release patch

• Side effects:

– Headache

– Hypotension

– Syncope

– V/Q mismatch

Sodium Nitroprusside (Nipride)

• Vasodilator used for hypertensive crisis

• IV dose:

– Loading dose of 50 –100 mg followed by infusion of .5-8 micrograms/kg/min

– Is light sensitive so IV bag must be wrapped in tin foil

• Side effects:

– Hypotension so patient must have continuous hemodynamic monitoring

Sodium Bicarbonate

• Used for METABOLIC acidosis hyperkalemia – H + HCO3 >H2CO3>H2O and CO2 – Airway and ventilation have to be functional!

• IV Dose: – 1 mEq/kg – If ABGs, [BE] x wt in kg/6

• Side effects: – Metabolic alkalosis – Increased CO2 production

Thrombolytics

• Used to improve coronary blood flow by lysing clots, ie coronary thrombosis – Best if given within six hours of onset of chest pain

– Examples: TPA/Alteplase(Activase), Streptokinase

• Side effects: – Bleeding

Further study: http://www.uptodate.com/contents/advanced-cardiac-

life-support-acls-in-adults

End of ACLS CE Part III THANK YOU FOR YOUR ATTENTION