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Transcript of ACLS Update
ACLS UpdateMarisha Chilcott, MDCCRMC Emergency Department
Audience SurveyWho 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 OpinionsWho 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 BlueReturn 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 dischargedLong-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 DetectiveRides road bike total of 250 miles during week of 10/5/08Goes for easy 3 mile training run w/ other officers 10/15/08Stretches 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 facePale, unresponsive, pulselessCompanion officers start EXCELLENT CPRSRFD on scene in less than 3 minutes, defibrillator pads placed, rhythm checked
V-Fib ArrestShock w/ 120 JoulesContinue EXCELLENT CPR (How do we know it was excellent?)Check pulse, check rhythm carotid pulse present, sinus rhythmTransport to Santa Rosa Memorial HospitalIn ER trauma bay, patient becomes alert, speaks coherently, and complains of being very sore
EpiloguePatient goes to cardiac catheter where he is diagnosed with severe 3 vessel diseaseUndergoes 3 Vessel CABGEP study demonstrates need for implantable defibrillatorHis friends take CPR and get their own cholesterol checked
Excellent CPR: Hard and FastNew ratio is 30:2Chest compressions are more important than rescue breathsCompressions delivered at 100/minute (staying alive, staying alive, ah, ah, ah)Ventilations 8-10/minute slower than you think
Rhythm CheckThere is only one question
To shock, or not to shockV-Fib or pulseless V-Tach SHOCKPEA or Asystole MEDS AND CONTINUED CPR
NEW: KEEP DOING CPR!After delivering a shock, resume CPR for 2 minutes before checking rhythm againSimultaneously check for pulseResume CPR while defibrillator charges, if need to shock again
Drugs WorkNO MORE ET Tube administrationIV access or IO access as soon as possibleEpinephrine/Vasopressin Q3-5 minutesAmiodarone after Epi/Vasopressin; Lidocaine also OK, but now out of favor and not in field protocols
VasopressinIndicated for V-Fib, V-Tach, PEA, Asystole;Give ONLY ONCE40 Units IV/IO instead of 1st or 2nd dose of EpinephrineNOT for responsive (talking) patients with known CAD
EpinephrineFirst line drug for ALL pulseless rhythms10 ml of 1:10,000 solution -- bolus1 mg in 500 ml of NaCl or D5W @ 1microgram/min, titrate to effect
AmiodaroneGive for V-Fib or pulseless V-Tach1st dose: 300 mg IV/IO2nd dose: 150 mg IV/IOInfuse: 0.5 mg/min x 18 hours
AtropineSymptomatic bradycardia or SLOW PEAPEA, Asystole: 1mg IV/IO Q3-5 minBradycardia: 0.5mg IV/IOQ3-5 min, PRNNote that dose < 0.5mg can cause paradoxical bradycardia
72 YO Caucasian Family DoctorSwimming, per his usual at the local poolNot feeling up to par, decides he should get outWakes up in ICUWhat happened?
By stander CPROral surgeon swimming in same lane starts poor quality CPR2 ER nurses, having breakfast @ poolside shove surgeon out of way and start excellent CPRParamedics arrive, and deliver 2 shocks in field between continued CPR, establishing a line and intubatingTransport to ER CPR continuing
ER Code BlueOn arrival to ER, rhythm remains VFibShock in ER and Amiodarone bolusRhythm converts to sinusTransferred to ICUImplantable defibrillator placed
CPR and Code Blue Success2 weeks later, back in the office5 years later, still swimming and seeing patients