Advanced Cardiac Life Support

question 3 West Coast University, School of Pharmacy Jessica Louie, PharmD, APh, BCCCP Associate Professor, Pharmacy Practice West Coast University, School of Pharmacy Spring 2024 ¡ List the common correctable causes of cardiac arrest ¡ Formulate a treatment plan (including drug doses) given a cardiac arrest situation (including VF/VT/PEA/Asystole/Bradycardia/Tachycardia) ¡ Discuss treatment strategies for post-resuscitative care following a cardiac arrest 2 ACLS Megacode by Simple CPR https://www.youtube.com/watch?v=90q19HTvm28 DiPiro et al. (2023) Pharmacotherapy: A Pathophysiologic Approach, 12th Edition. McGrawHill. Chapter 41 AED Device by AmericanSTI https://www.youtube.com/watch?v=3trpw_We0UQ Recommended: § American Heart Association Guidelines for CPR & ECC Example: https://www.youtube.com/watch?v=_Qd_3C09RWY § https://eccguidelines.heart.org/index.php/circulation/c https://youtu.be/XQ5XEDC2aFw pr-ecc-guidelines-2/ 3 Jessica M. Louie, PharmD, APh, BCCCP Differentiate between shockable and non-shockable rhythms and state the sequence of events in the chain of survival 1 Required: § ¡ Spring 2024 4 1 West Coast University, School of Pharmacy Term ACLS AED AHA BLS CPP CPR ECC ECMO EMS ETCO2 Spring 2024 Definition Advanced cardiac life support Automated external defibrillator American Heart Association Basic life support Coronary perfusion pressure Cardiopulmonary resuscitation Emergency cardiovascular care Extracorporeal membrane oxygenation Emergency medical services End-tidal carbon dioxide Term IO MI PEA ROSC ScvO2 VF VT Definition Intraosseous Myocardial infarction Pulseless electrical activity Return of spontaneous circulation Central venous oxygen saturation Ventricular fibrillation Ventricular tachycardia 5 6 7 8 Fs Torsades de Pointes Jessica M. Louie, PharmD, APh, BCCCP 2 West Coast University, School of Pharmacy Spring 2024 Fo The 6 links in the adult out-of-hospital Chain of Survival are: • Recognition of cardiac arrest and activation of the emergency response system • Early cardiopulmonary resuscitation (CPR) with an emphasis on chest compressions • Rapid defibrillation • Advanced resuscitation by Emergency Medical Services and other healthcare providers • Post-cardiac arrest care • Recovery (including additional treatment, observation, rehabilitation, and psychological support) ¡ 9 10 11 12 High-quality CPR § Rate: 100-120 beats/min § Depth: at least 2 inches § Recoil: allow for full recoil § Interruptions: minimize interruptions to less than 10 seconds § Switch compression team members every 2 minutes Jessica M. Louie, PharmD, APh, BCCCP 3 West Coast University, School of Pharmacy Spring 2024 MA is a 58 y/o male who presents to the ED with vomiting who is acutely anxious for unknown reasons. Shortly after triage in the ED he loses his pulse. The ED code team is summoned. ¡ What is the most appropriate regarding initial resuscitation efforts for MA? A. Should receive rescue breaths immediately B. Needs STAT intravenous access C. Should receive chest compressions immediately D. Should have pacing pads placed Jessica M. Louie, PharmD, APh, BCCCP 13 14 15 16 4 West Coast University, School of Pharmacy ¡ 2 options: § Basic: bag-mask ventilation Spring 2024 A Fyi § Advanced: endotracheal intubation ¡ Basic tenets: § Provide sufficient oxygen for arterial oxygen delivery § Allow for ventilation § Avoid excessive positive pressure ventilation (reduces venous return) 17 ¡ 18 Goal: successful defibrillation § ≥ 5 seconds of termination of arrhythmia after shock delivered ¡ 3 key actions impact mortality: § Activate emergency medical services § Provision of CPR (while waiting for AED or manual defibrillator) § Early shock delivery when appropriate ¡ Energy delivered depends on type § Monophasic = 360 Joules § Biphasic = manufacturer’s recommendation (e.g. 120- 200 Joules) ¡ ¡ 19 Jessica M. Louie, PharmD, APh, BCCCP CPR should resume immediately after shock and continue for 2 minutes before rhythm or pulse check If multiple shocks needed, always deliver previous successful energy or higher 20 5 West Coast University, School of Pharmacy ¡ Spring 2024 Chest compressions are performed immediately as BLS is initiated. The team is working on intravenous access, advanced airway placement, and MA has defibrillator pads placed. He is found to be in ventricular fibrillation. AED Device Which of the following is correct? A. MA should receive STAT dose of amiodarone 300mg IO MA should receive STAT dose of 200 J from manual biphasic defibrillator C. Chest compressions should cease so MA can have an advanced airway placed B. D. 21 ¡ Consider reversible causes: ¡ Treatable Causes of Cardiac Arrest: The H’s and T’s Hypoxia Toxins Hypovolemia Tamponade (cardiac) Hydrogen ion (acidosis) Tension pneumothorax Hypo/hyperkalemia Thrombosis, pulmonary Hypothermia Thrombosis, coronary Goal: increase myocardial blood flow and increase return of spontaneous circulation (ROSC) Central IV/IO • Higher peak concentrations • Shorter time to target receptors • Difficult to obtain access (IV) 23 Jessica M. Louie, PharmD, APh, BCCCP A STAT dose of 120 J from manual monophasic defibrillator should be delivered. 22 Peripheral IV • Longer time to reach target receptors • Medication bolus requires flush (e.g. 10-20 mL bolus of 0.9% NaCl) • Ease of access Endotracheal • Unknown target doses: typically 22.5x IV dose • Limited medication selection • Dilute with 5-10 mL of 0.9% NaCl or sterile water • Lower serum concentrations 24 6 West Coast University, School of Pharmacy Spring 2024 Endotracheal administration of medications § V = vasopressin Medication MOA Epinephrine Alphaadrenergic agonist O § E = epinephrine § L = lidocaine *previous guidelines also recommended naloxone and atropine via endotracheal administrations Dose Clinical benefit 1 mg IV/IO every ↑coronary perfusion and 3-5 minutes cerebral perfusion pressure (CPP) during CPR ↑ ROSC 25 Medication Amiodarone Lidocaine MOA Na/K/Ca channel & betaantagonist Na channel antagonist Dose 1st dose: 300 mg IV/IO x1 26 Clinical benefit Out-of-hospital VF/VT increased survival vs. lidocaine or placebo 2nd dose: 150 mg IV/IO x1 1st dose: 1-1.5 Consider after ROSC mg/kg IV/IO x1 from VF/VT cardiac arrest § Shockable rhythm – type of polymorphic ventricular tachycardia occurring with QT prolongation § Give magnesium sulfate 1-2 gram diluted in 10 mL of sterile water or D5W IV/IO 2nd dose: 0.5-0.75 mg/kg q5-10 min Max 3 mg/kg cumulative dose 27 Jessica M. Louie, PharmD, APh, BCCCP 28 7 West Coast University, School of Pharmacy Spring 2024 § Cornerstone of therapy is to address reversible/treatable causes of cardiac arrest § Epinephrine can be given every 3-5 minutes § Emphasis on airway management if hypoxic cardiac arrest 29 30 A shock is delivered to MA and chest compressions immediately restarted. MA has peripheral intravenous access, a right proximal humerus IO and weights 100 kg. Which of the following is correct about the most appropriate medication management for MA? MA should receive a dose of: 31 Jessica M. Louie, PharmD, APh, BCCCP A. Amiodarone 300 mg IO B. Sodium bicarbonate 50 mEq IV C. Lidocaine 100 mg IV D. Epinephrine 1 mg IO ThenA 32 8 West Coast University, School of Pharmacy Jessica M. Louie, PharmD, APh, BCCCP Spring 2024 33 34 35 36 9 West Coast University, School of Pharmacy Jessica M. Louie, PharmD, APh, BCCCP Spring 2024 37 38 39 40 10 West Coast University, School of Pharmacy Spring 2024 ¡ WHO: all comatose adult patients with ROSC after cardiac arrest should have TTM ¡ WHAT: goal temperature of 32-36°C ¡ WHEN: ¡ WHY: § Initiation: as soon as possible (within 6-8 hours of cardiac arrest) § Duration: at least 24 hours § Prognosis: wait at least 72 hours after completion of TTM for prognostication of patient 41 42 c yl ¡ for HOW: Phase 1: Cooling § Reduces shivering threshold Phase 2: Maintenance § APAP 650 mg q4-6 hours Phase 3: Rewarming § Buspirone 30 mg q8-12 hours • Cold IV fluids, ice • Avoid excessive cooling: • Rewarming should packing, internal and occur over ~8 hours keep temperature >30°C external cooling devices • Complications: at rate of 0.33-0.5°C • Ensure adequate per hour bradycardia, sedation • Continue deep hyperglycemia, • Major complications: sedation until warm electrolyte depletion, ↓ shivering and seizures • Complications: GFR, coagulopathy electrolyte shifting, hypotension 43 Jessica M. Louie, PharmD, APh, BCCCP § Dexmedetomidine or clonidine § Stop shivering § Deepen sedation § Initiate paralysis § Surface warming § Cold fluids 44 11 West Coast University, School of Pharmacy Spring 2024 redness cause fests Thank you for your attention After 10 minutes of resuscitation, MA has ROSC but remains comatose. Which of the following is correct about targeted temperature management for MA? A. Initiate therapeutic hypothermia as it can improve neurologic recovery B. Initiate therapeutic hypothermia as it increases survival C. Do not initiate therapeutic hypothermia because his rhythm was VF and this was not studied D. Do not initiate therapeutic hypothermia because he does not have resulted baseline lab values ANY QUESTIONS??? 45 Jessica M. Louie, PharmD, APh, BCCCP Jessica Louie, PharmD, APh, BCCCP jLouie@westcoastuniversity.edu 46 12