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ACLS Update

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?

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ACLS Update

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  1. ACLS Update Marisha Chilcott, MD CCRMC Emergency Department

  2. 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?

  3. 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?

  4. 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)

  5. 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

  6. 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…

  7. 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

  8. 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

  9. 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

  10. 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

  11. 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

  12. 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

  13. 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

  14. 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

  15. 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

  16. 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

  17. 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?

  18. 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

  19. 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

  20. CPR and Code Blue Success • 2 weeks later, back in the office • 5 years later, still swimming and seeing patients

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