Advanced Cardiac Life Support

 

Code Blue Hints

Conditions Associated With Cardiac Arrest

Comprehensive ACLS Algorithm

     VF And Pulseless VT

     Pea

     Asystole

     Stable  VT

     Bradycardia

     Tachycardia

 

 

CODE BLUE HINTS

 

1.      Stay calm, check your own pulse!

·        Familiarize yourself with the equipment on your ward(s) or hospital.

·        In preparation for a possible code blue, identify specific roles for different members of your team (e.g. assign one person to chest compressions, another to establish central IV access, etc).  

·        Remember the basics: CPR, defibrillation, airway management (don't get caught up in memorizing drug dosages).

 

2.      Always identify yourself as the code leader.

 

3.      Talk out loud through the thinking process and algorithms.

 

4.      At the start of the code, appoint specific people to specific tasks:

·        Get crash cart/defibrillator/backboard.

·        Get information and chart.

·        Establish airway (bag mask, intubate).

·        Establish IV access, check pulse.

·        Perform chest compressions.

·        Get ABG, check labs.

·        Nursing (give meds, place leads, etc).

·        Pharmacist (deliver meds).

 

5.      When applying monitor leads to patient, remember: "white to the right, smoke above fire" (white on right shoulder, black on left shoulder and red near precordium on left).

 

6.      If performing chest compressions:

·        Remember to get a backboard under the patient.

·        The optimal rate is 100 times a minute.  Your job when performing compressions is to circulate the patient's blood effectively (important for cerebral perfusion and for circulation of medications).

 

7.      Defibrillator/monitor:

·        Always check lead placement and check asystole or a questionable rhythm in 2 leads.

·        When defibrillating with paddles, use 25 lbs. of pressure.

·        Do not shock asystole.  Take time to confirm that the rhythm is not coarse VF.

 

8.      For tachycardia, ejection fraction guides treatment (try to find in patient's chart).

 

9.      Remember the five H's and the five T's for PEA and asystole:

·        5 H's: hypovolemia, hypoxia, hydrogen ion (acidosis), hyper/hypokalemia, hypothermia.

·        5 T's: tablets (drugs), tamponade, tension PTX, thrombosis (coronary), thrombosis (PE).

 

10.   No high dose epinephrine.

 

11.   Don't forget to check code status prior to starting ACLS (make sure you have the right chart!).

 

 

CONDITIONS ASSOCIATED WITH CARDIAC ARREST

 

Condition	Clinical Setting	Treatment
Acidosis	Diabetes, diarrhea, drugs, toxins, prolonged resuscitation, renal failure, shock/sepsis, preexisting acidosis.	·        Ensure adequate CPR, oxygenation, ventilation. ·        Hyperventilate. ·        If pH < 7.20 consider HCO3.
Hypothermia	EtOH, burns, CNS disease, debilitated, homeless, or elderly pt, drowning, drugs, toxins, endocrine disease, exposure, trauma, spinal cord disease.	·        If severe (< 30ºC), limit initial shocks for VF/VT to three. ·        Active internal warming and resuscitation. ·        Goal is to first get T > 30ºC, then restart ACLS.
Hypovolemia	Hemorrhage, diabetes, GI loss, shock, major burns, trauma.	·        Fluids, PRBC's, look for site of loss if applicable.
Hypoxia	Consider in all patients with cardiac arrest.	·        Ensure adequate CPR, oxygenation, ventilation, correct ETT placement.
Hypokalemia	EtOH, diabetes, diuretic use, drugs, toxins, profound GI loss, hypomagnesemia.	·        If < 2.5 mEq/L and associated with cardiac arrest, give 2 mEq/min IV up to 10-15 mEq and reassess.
Hyperkalemia	Renal failure, dialysis patients, metabolic acidosis, drugs, toxins, hemolysis, rhabdomyolysis, massive tissue injury.	·        10% calcium chloride 5-10 ml IV slow push (don't give if hyperkalemia due to dig toxicity). ·        1 amp D50 IV. ·        10 U regular insulin IV. ·        1-2 amps of HCO3 IV. ·        Albuterol nebs.
HypoMg	EtOH, DKA, severe diarrhea, diuretics, burns, drugs.	·        1-2 g IV MgSO4 IV over 2 minutes.
Myocardial infarction	Consider in all patients with cardiac arrest and especially those with pre-existing coronary disease or risk factors.	·        Consider thrombolytics, emergent cardiac catheterization, or urgent CABG.
Cardiac Tamponade	Hemorrhagic diathesis, post MI, pericarditis, trauma, post-cardiac surgery.	·        Administer fluids. ·        Obtain bedside echo if possible. ·        Urgent pericardiocentesis. ·        Surgical intervention if appropriate.
Poisoning	EtOH, unusual behavioral or metabolic presentation, exposure, psychiatric disease, classic toxicologic syndrome.	·        Send tox screen, consult toxciologist. ·        Treat suspected ingestion. ·        Prolonged resuscitation may be appropriate.
Pulmonary Embolism	Hospitalized patient, recent surgery, peripartum, history of DVT, risk factors for DVT.	·        Adminster fluids, pressors as needed attempt to confirm diagnosis. ·        Consider thrombolytics or urgent surgical intervention.
Tension Pneumothorax	Placement of central line, mechanical ventilation, lung disease, thoracentesis, trauma.	·        Needle decompression: 14 guage angiocath at 2nd ICS, MCL. ·        Chest tube placement.

 

Eisenberg MS, Mengert TJ.  Cardiac resuscitation.  N Engl J Med. 2001 Apr 26;344(17):1304-13.

 

 

COMPREHENSIVE ACLS ALGORITHM

 

1.      Unresponsive? Go to primary ABCD (basic life support):

·        A = open airway

·        B = give 2 breaths

·        C = check pulse

·        D = get defibrillator

 

2.      Use defibrillator to check rhythm:

• If VF/VT: give 3 shocks, begin CPR
• If PEA or asystole: begin CPR immediately.

 

3.      Go to secondary ABCD:

• A = intubate the airway: endotracheal tube (ETT)or laryngeal mask airway (LMA).
• B = confirm position of ETT objectively with end tidal CO₂ and O₂ saturation and secure airway to prevent dislodgement so that patient can breathe.
• C = IV access, continue CPR, give vasoconstrictor agent (vasopressin or epinephrine) and then consider antiarrhythmics, buffer, pacer for circulation, cardiovascular support.
• D = differential diagnosis: look for the reversible causes (5 H's and 5 T's).

 

4.      Follow the appropriate algorithm and switch to a different algorithm as needed.

 

 

VENTRICULAR FIBRILLATION AND PULSELESS VT

 

1.      Follow the protocol: shock ® shock ® shock (200J, 300J, 360J) ® drug ® shock (360 J) ® drug ® shock (360J) ® etc.

 

2.      First give vasoconstrictor agent:

• Vasopressin 40 U IV x 1 ® if no response give epinephrine as below.
• Epinephrine 1 mg IV q 3-5 minutes.

 

3.      Then give antiarrhythmic agent:

• First line: Amiodarone 300 mg IV rapid push, can repeat 150 mg IV x 1.
• Second line:

-        Lidocaine 1.0-1.5 mg/kg (70-100 mg) IV q 3-5 minutes up to a total of 3 mg/kg.

-        Magnesium 1-2 g IV (mainly for hypomagnesemic state or polymorphic VT).

-        Procainamide 30 mg/min IV up to 17 mg/kg total (not recommended in refractory VF).

 

4.      Buffer:

·        Bicarbonate 1-3 amps IV (first line for hyperkalemia; less evidence for prolonged arrest, TCA overdose, aspirin overdose).

 

 

PULSELESS ELECTRICAL ACTIVITY (PEA)

 

1.      First give vasoconstrictor agent for cardiovascular support while you search for a cause.

• Vasopressin 40 U IV x 1 or
• Epinephrine 3-5 mg IV q3-5 minutes.

 

2.      Give atropine if the PEA rhythm is slow:

·        Atropine 1 mg IV q 3-5 minutes to total of 0.04 mg/kg (3-4 doses for most patients)

 

3.      Finding a reversible cause is key.  While you are searching, follow steps #4-8.

 

4.      Correctpresumed hypovolemia and hypoxia:

• Fluids, fluids, fluids – wide open.
• Intubate immediately.

 

5.      Correct presumed hyperkalemia and acidosis:

• Give 1-3 amps HCO₃ IV.

 

6.      Consider hypothermia and overdose:

• Actively warm the patient (if they are hypothermic).
• Check the chart and history for evidence of overdose.

 

7.      Rule out tamponade and pneumothorax (PTX):

• Consider insertion of needle at subxiphoid space directed at 45 degrees toward left shoulder for tamponade.
• Consider insertion of 14 gauge angiocath into 2^nd intercostal space, midclavicular line on side of PTX.

 

8.      Consider thrombosis (massive MI or PE):

• Consider TPA or emergency PTCA/CABG for MI.
• Consider TPA for massive PE.

 

 

ASYSTOLE

 

1.      Carries a poor prognosis.

 

2.      Review differential diagnosis just as in PEA algorithm.

 

3.      First line: transcutaneous pacing should be started immediately.

 

4.      Adrenergic agent: for cardiovascular support while you search for a cause:

• Epinephrine 1 mg IV q 3-5 minutes.
• Atropine 1 mg IV q 3-5 minutes to total of 0.04 mg/kg (3-4 doses for most patients).

 

5.      If refractory:

• Review quality of resuscitation.
• Look for atypical clinical features (hypothermia, drug overdose).
• If > 10 minutes with adequate effort and no atypical features consider stopping code.

 

 

 

STABLE VENTRICULAR TACHYCARDIA (VT)

 

1.      If the patient is unstable or becomes unstable go directly to cardioversion.  In addition, you may proceed directly to cardioversion, even if the patient is stable.

 

2.      Is it monomorphic VT? Look at the ejection fraction (EF).

• For normal EF: use sotalol or procainamide.  Also can use amiodarone or lidocaine.
• For low EF:give amiodarone 150 mg IV x 1 and proceed to synchronized cardioversion.

 

3.      Is it polymorphic VT? Look at the baseline QT interval.

• Prolonged QT (prior to VT): suggests torsades.  Correct electrolytes and give magnesium IV.  Consider overdrive pacing.
• Normal QT (prior to VT): correct ischemia and/or electrolytes.  If EF normal, can give beta-blocker, lidocaine, amiodarone, sotalol, or procainamide.  If EF low, give amiodarone 150 mg IV.

 

 

BRADYCARDIA

 

1.      See also Night calls: Bradycardia.

 

2.      Primary then secondary survey including 12-lead ECG.

 

3.      Serious signs/symptoms?

• Atropine 0.5-1.0 mg IV q 3-5 minutes up to 0.04 mg/kg (3-4 doses for most patients).
• Transcutaneous pacing.
• Dopamine 5-20 mcg/kg/minute.
• Epinephrine 2-10 mcg/minute.

 

4.      Is there type II second degree AV block or third degree AV block?

• Proceed to transcutaneous pacing until transvenous pacer can be placed.

 

 

TACHYCARDIA

 

1.      See also Night calls: Tachycardia.

 

2.      Is the patient unstable (chest pain, shortness of breath, altered mental status, loss of consciousness, hypotension, congestive heart failure, myocardial infarction)?

• If unstable and HR is cause ® go to cardioversion.

 

3.      If stable, get 12-lead ECG and classify arrhythmia.  Then treat specific rhythm as clinically indicated.