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
What are the players?
1. Defib (shock)
- 2. Vasopressors
- 3. Antiarrhythmic
- Magnesium sulfate
Patient alarms sounds
Patient unresponsive and you see VF on monitor.
Pulse check: none
What do you do?
- Get Pads ready
- Defib after 2 min of CPR
What is the energy dose for defibrillation?
When in doubt -> 200 J
- Monophasic -> 360 J
- Biphasic -> 200J
- Biphasic Truncal -> 120 J
Subsequent shocks should be?
Same or higher Joules
What should you do immediately before 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.
After one shock and one 2 min of CPR, rhythm shows VF still.
What do you do next?
- Repeat SHOCK
- Give Vasopressor
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
Why do we use vasopressors?
Vasopressors optimizez cardiac output and blood pressure
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
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
patient now recieved
shocks, cpr, shock & Epi, cpr...
still in VF now what?
SHock again!, CPR
Consider antiarrhythmic drug
*Magnesium if Torsades.
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.
up to 3 doses
- 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
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.
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
VF, Pulseless VT treatment sequence
- Prepare pads, deliver 1 Shock
- Resume CPR for 2 min
- Check Rhythm
Shock, CPR, Vasopressor
Shock, CPR, consider Antiarrythmic
What meds do you use for postresuscitation maintenance therapy for recurrent VF/VT
Amiodarone or Lidocaine
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.
when do you use AED
- No response
- NO breathing
- No pulse!
At what age do you use child pads