*Person Collapses (Adult, assume cardiac arrest)
*Assess Responsiveness (Shake and Shout or if trauma, Touch and Talk
to pt) "Are you awake?"
*Activate emergency response system (call 911 or if in a medical setting
call a code blue or call for a defibrillator) - the main rhythm
associated with cardiac arrest in an adult is V.fib/Pulseless V. Tach
and NEEDS to be shocked as soon as possible to survive.
Begin the Primary Survey
A=Airway, Open and assess airway. Use head tilt-chin lift or if trauma suspected jaw thrust method to open the airway. Look (for chest rise), listen (over the mouth for air movement), and feel (for breathing against our face). Treat occasional gasps as if not breathing. The new guidelines recommend that if in the field and ALONE (one person), open all airways by head tilt-chin lift. The rationale is that one person doing a jaw thrust will need to stay and maintain that head positioning. It is more of a priority to open the airway and breath for the patient than it is to maintain the head in proper alignment.
B=Breathing, take 5-10 seconds to check for breathing. If none, give 2 slow breaths over 1 second and enough to cause visible chest rise. If the first does not go in, reposition the head (reopen the airway) and try again.
C=Circulation, Assess pulse and skin color and movement from pt for signs of circulation. If no carotid pulse within 10 seconds, start Chest Compressions hard (1 1/2 to 2 inches) and fast (100 compressions per minute). (Give 30 chest compressions for every 2 breaths for two minutes, then switch). If there is a pulse, still rescue breathe for the pt 10-12 times per minute, give a breath enough to cause chest rise and complete recoil.
Helps Arrives with a defibrillator.
**Note: Pneumonic for those who just want the quick and dirty. Use it if it helps, below is a more in depth discussion of each intervention**
Shock (120 to 200joules - biphasic and 360joules - monophasic)
EVerybody Shock, (Epinephrine 1mg IV q3-5min or Vasopressin
40Units IV, 1 x dose, then Shock)
And - (Amiodarone 300mg IV push, repeat 150mg in 3-5 minutes)
Let's - (Lidocaine 1-1.5mg/kg IV push repeat in 3-5 minutes to a max dose of
3mg/kg)
Move - (Magnesium Sulfate 1-2gm IV over 1-2 min.)
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(Procainamide gtt 30mg/min IV or 100mg IV boluses q 5min to max dose of 17mg/kg) - less emphasis because it takes time to much time
to run in as a drip.
(Bicarbonate 1mEq/kg IV push q 10min under certain
circumstances like hyperkalemia, certain drug overdoses, and for some acidotic conditions). It is not liberally or prophylactically given.
P in Please = Precordial Thump. No evidence shows a beneficial conversion from VT to a perfusing rhythm, but some evidence shows a deterioration. Therefore, it is not recommended one way or the other any longer.
D=Defibrillation, Attach to a defibrillator-monitor or with paddles do a quick look for a shockable rhythm. We are looking for Ventricular Fibribllation or PULSELESS Ventricular Tachycardia to defibrillate. Make sure the SYNC button is off.
Place paddles or patches one over apex (~ left side 5th ICS at anterior axillary line) of the heart and the other at right up chest (right sternal border at 2nd ICS.) If using paddles, make sure you use a water soluble gell or two 4x8s moistened with normal saline and use 25 lbs of pressure to prevent arching.
One Shock
Defibrillate one time if needed for persistent Ventricular Fibrillation (V. Fib.) or Ventricular Tachycardia (V. Tach.), in succession, do not stop if rhythm still present with each shock:
120 to 200joules - biphasic or 360joules - monophasic.
*monophasic or biphasic energy may differ, see manufacturer of your AED or Defibrillator for details.
**Remember it is your responsibility to make sure no one touches the patient or anything touching the patient.**
Call out: "I'm clear! Your clear! Everyone clear!"
Look at the rhythm after one shock and ask is the patient still in V. Fib. or V. Tach.?
If so, then proceed to the Secondary ABCD survey.
A=Airway-place an airway device as soon as possible, this provides an airway and a drug route.
B=Breathing-confirm airway device by exam and another confirmation device, secure the airway with an approved device, and bag pt with 100% oxygen, confirm oxygenation and effective ventilations by chest rise.
C=Circulation, recheck pulse and rhythm and continue to do CPR if no pulse, place IV, antecubital vein is 1st choice or Intraosseous access. Administer drugs appropriate for rhythm and condition. In this case, V. fib/Pulseless V. tach., give
E in everybody = Epinephrine 1 mg IV q3-5 min.
or
V in everybody = Vasopressin 40 Units IV, one time dose or after 1st or 2nd dose of Epinephrine.
(wait 10-20 minutes before starting epinephrine)
Flush with 20 mL NS or run IVFs to keep meds running into the vein and raise the arm.
After giving the drug, then resume CPR for 30 - 60 seconds to help circulate the medication, remember the only heartbeat is the one your manually give the patient.
Stop CPR and Reassess pulse and rhythm.
Then, Shock = Defibrillate 120 to 200joules - biphasic or 360joules - monophasic
Reassess pulse and rhythm and if no pulse and still in V.fib or V.tach then resume CPR.
Continue in a drug-CPR-shock-drug-CPR-shock sequence.
Next, consider antiarrhythmics and buffers. Note these next drugs blend in with the next step. Give the medications as ACLS notes except when clinical conditions warrent otherwise.
A in And = Amiodarone 300mg IV push, repeat in 3-5 minutes with 150mg IV. If starting an infusion, run 1 mg/min for 6 hours, then 0.5 mg/min for rest of time with max dose 2.2 grams in 24 hours.
L in Let's = Lidocaine 1mg/kg - 1.5mg/kg (quick conversion on weight is take the weight in lbs - then divide by 2.2 = weight in kg. Lidocaine comes in 100 mg syringes). IV push repeat in 3-5 minutes with half the dose (0.5 - 0.75 mg/kg to a maximum of 3mg/kg.
M in Make = Magnesium Sulfate 1-2grams IV over 1-2minutes for hypomagnesium state or Torsades de pointes. The rhythm does not get bigger and smaller like seen with polymorphic V. Tach. at times. It twists on its axis. In this picture from http://img.medscape.com/fullsize/migrated/561/317/jce561317.fig1.gif it shows the upright QRS starting out, then the twist and the QRS pointing down, then another twist and it points up again.
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P in Patients = Procainamide 30mg/min IV gtt, takes about 20 minutes to get in. (Not practical in a code because it takes so long to get in.)
B in Better = Bicarbonate (NaHCO3-Sodium Bicarbonate) 1mEq/kg IV q 10 minutes - class 1 intervention for hyperkalemia, used for certain drug overdoses to alkalinize the urine and metabolic acidosis, contraindicated in respiratory acidosis, not used prophylactically.
I'll explain some of the inverventions below with the next step as to how some might fit in earlier in the process.
Unconscious adult patients that were out of the hospital with Ventricular Fibrillation as the initial rhythm be cooled to 32ºC to 34°C for 12 to 24 hours. Similar therapy may be beneficial for patients with other arrest rhythms. Further research is needed.
See PEA algorithm for a detailed description of each.
D=Differential Diagnosis, Search for and treat reversible causes including but not limited to 5 Hs and 5 Ts:
Hypovolemia-give fluids and/or blood products (the #1 cause of PEA),
Hypoxia-give 100% ventilated oxygen,
Hypo/hyperkalemia(low or high K level)-give KCL boluses not more than 20mEq per hour for low K+ level/-give NaHCO3 1mEq/kg IV q 10 minutes for high K+ level,
Hydrogen Ion (acidosis)-hyperventilate pt or give NaHCO3 depending upon lab values,
Hypothermia/Hyperthermia-warm pt with blankets and warmed IVFs for hypothermia. Keep the patient from getting too warm.
Hypoglcemia - treat with IV dextrose, but don't let blood sugar get too high keep about (80-110).
Thrombosis Pulmonary (PE)-thrombolytics or surgery to remove the blockage,
Thrombosis Cardiac (MI)-thrombolytics or surgery to remove the blockage,
Tension Pneumothorax-needle decompression,
Tamponade, Cardiac -paracardial centesis,
Tablets (OD)-give NaHCO3 for certain antidepressants.
Trauma - treat the underlying problems such as source of bleeding, surgical needs, respiratory support, electrolyte imbalances, etc.
