ACLS Update

Marisha Chilcott, MD

CCRMC Emergency Department

Audience Survey

• Who has been certified in ACLS in last 3 years?

• Who was certified before then?

• Anyone ever give bystander CPR or CPR in the field?

• When was last time you participated in a Code Blue that had a really good outcome?

Audience Opinions

• Who thinks that CPR works?

• Can you actually save anyone?

• Would you initiate CPR as a bystander?

• Who has talked to Ann Lockhart or Elise Lewis about their experience on the reservoir run?

Grim Statistics for Code Blue

• Return of spontaneous circulation (ROSC) of about 40% - 60%

• Survival to hospital discharge of at most 15%

• Long term (3 year) survival ~40% OF the 15% that are discharged

• Long-term survival after successful in hospital cardiac arrest resuscitation American Heart Journal - Volume 153, Issue 5 (May 2007)

• Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of "limited" resuscitations. - Dumot JA - Arch Intern Med - 23-JUL-2001; 161(14): 1751-8 (From NIH/NLM MEDLINE)

38 YO Asian Male Homicide Detective

• Rides road bike total of 250 miles during week of 10/5/08

• Goes for easy 3 mile training run w/ other officers 10/15/08

• Stretches post run; reaching for the sky is the last thing he remembers until waking in the ER

What Happened While He was Asleep?

• Collapsed forward, striking head and face

• Pale, unresponsive, pulseless

• Companion officers start EXCELLENT CPR

• SRFD on scene in less than 3 minutes, defibrillator pads placed, rhythm checked…

V-Fib Arrest

• Shock w/ 120 Joules• Continue EXCELLENT CPR (How do we know it was excellent?)

• Check pulse, check rhythm – carotid pulse present, sinus rhythm

• Transport to Santa Rosa Memorial Hospital

• In ER trauma bay, patient becomes alert, speaks coherently, and complains of being very sore

Epilogue

• Patient goes to cardiac catheter where he is diagnosed with severe 3 vessel disease

• Undergoes 3 Vessel CABG

• EP study demonstrates need for implantable defibrillator

• His friends take CPR and get their own cholesterol checked

Excellent CPR: Hard and Fast

• New ratio is 30:2

• Chest compressions are more important than rescue breaths

• Compressions delivered at 100/minute (staying alive, staying alive, ah, ah, ah…)

• Ventilations 8-10/minute – slower than you think

Rhythm Check

• There is only one question…

• To shock, or not to shock

• V-Fib or pulseless V-Tach • SHOCK

• PEA or Asystole

• MEDS AND CONTINUED CPR

NEW: KEEP DOING CPR!

• After delivering a shock, resume CPR for 2 minutes before checking rhythm again

• Simultaneously check for pulse

• Resume CPR while defibrillator charges, if need to shock again

Drugs Work

• NO MORE ET Tube administration

• IV access or IO access as soon as possible

• Epinephrine/Vasopressin Q3-5 minutes

• Amiodarone after Epi/Vasopressin; Lidocaine also OK, but now out of favor and not in field protocols

Vasopressin

Indicated for V-Fib, V-Tach, PEA, Asystole;

Give ONLY ONCE

• 40 Units IV/IO instead of 1st or 2nd dose of Epinephrine

• NOT for responsive (talking) patients with known CAD

Epinephrine

First line drug for ALL pulseless rhythms

• 10 ml of 1:10,000 solution -- bolus

• 1 mg in 500 ml of NaCl or D5W @ 1microgram/min, titrate to effect

Amiodarone

Give for V-Fib or pulseless V-Tach

• 1st dose: 300 mg IV/IO

• 2nd dose: 150 mg IV/IO

• Infuse: 0.5 mg/min x 18 hours

Atropine

Symptomatic bradycardia or SLOW PEA

• PEA, Asystole: 1mg IV/IO Q3-5 min

• Bradycardia: 0.5mg IV/IOQ3-5 min, PRN

• Note that dose < 0.5mg can cause paradoxical bradycardia

72 YO Caucasian Family Doctor

• Swimming, per his usual at the local pool

• Not feeling up to par, decides he should get out

• Wakes up in ICU

• What happened?

By stander CPR

• Oral surgeon swimming in same lane starts poor quality CPR

• 2 ER nurses, having breakfast @ poolside shove surgeon out of way and start excellent CPR

• Paramedics arrive, and deliver 2 shocks in field between continued CPR, establishing a line and intubating

• Transport to ER – CPR continuing

ER Code Blue

• On arrival to ER, rhythm remains VFib

• Shock in ER and Amiodarone bolus

• Rhythm converts to sinus

• Transferred to ICU

• Implantable defibrillator placed

CPR and Code Blue Success

• 2 weeks later, back in the office

• 5 years later, still swimming and seeing patients