ACLS Update

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

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8
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

9
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

10
Excellent CPR Hard and Fast

• New ratio is 302
• 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

11
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

12
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

13
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

14
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

15
Epinephrine

• First line drug for ALL pulseless rhythms
• 10 ml of 110,000 solution -- bolus
• 1 mg in 500 ml of NaCl or D5W _at_ 1microgram/min,
  titrate to effect

16
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

17
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 lt 0.5mg can cause paradoxical
  bradycardia

18
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?

19
By stander CPR

• Oral surgeon swimming in same lane starts poor
  quality CPR
• 2 ER nurses, having breakfast _at_ 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

20
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

21
CPR and Code Blue Success

• 2 weeks later, back in the office
• 5 years later, still swimming and seeing patients