Columbia Medicine House Staff Training Program Series - ACLS...A.K.A. THE CODE PRIMER Course Objectives Background information on cardiac arrests Code leader / code team roles and
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Columbia Medicine House Staff Training Program Simulation Series : Advanced Cardiopulmonary Life Support A.K.A. THE CODE PRIMER
Simulation Series : Advanced Cardiopulmonary Life Support
A.K.A. THE CODE PRIMER
Course Objectives
Background information on cardiac arrests Code leader / code team roles and
responsibilities BLS/ACLS core concepts and algorithms Biphasic defibrillators Review scenarios
Presenter
Presentation Notes
Sudden cardiac arrest (SCA) is the second leading cause of death in both the United States and Canada [4-6], outranked only by cancer. Four hundred thousand to 460,000 people in the United States [7,8] and 700,000 people in Europe [9,10], suffer SCA each year. The most common etiology of SCA is ischemic cardiovascular disease resulting in the development of lethal arrhythmias [11-13]. Although resuscitation is attempted in up to two-thirds of people who sustain SCR, survival rates remain low, despite the development over the past 50 years of cardiopulmonary resuscitation (CPR), electrical defibrillation, and other advanced resuscitative techniques [14-16]. Assessments of survival from SCA have reached widely disparate conclusions. In the out-of-hospital setting, studies have reported survival rates of 1 to 6 percent [17-19]. Three systematic reviews of survival-to-hospital discharge from out-of-hospital SCA reported 5 to 10 percent survival among those treated by emergency medical services (EMS) and 15 percent survival when the underlying rhythm disturbance was ventricular fibrillation (VF) [19-21]. An analysis of a national registry of in-hospital SCA reported a 17 percent survival to discharge [22]. Poor performance of CPR is one factor contributing to poor outcomes. Multiple studies assessing both in-hospital and prehospital performance of CPR have shown that trained healthcare providers consistently fail to meet basic life support guidelines [23,24].
Resident Preparation
Surveys from academic training centers 79% residents are scared 76% resident wanted more teaching 82% residents wanted more experience
Pre-Code Essentials
Review BLS/ACLS core concepts Familiarize yourself with equipment Identify specific roles and responsibilities
within the code team RELAX…. you’ll be great!
Presenter
Presentation Notes
Perspective
Prognosis of cardiac arrest is poor (both in hospital and out of hospital)
Especially poor for those in PEA or Asystole ABCs and early defibrillation of VF/VT is
key – we only run to arrests so we can defibrillate VF/VT
VF/VT: Rapid Defibrillation is KEY!
The Columbia Arrest Resident
Designated code residents in CCU Short call resident until 5pm Long call resident after 5pm (responds to all
arrests, but care transferred to cardiology resident/night float when able)
Short call resident responsible for the daily test and change of the defibrillator battery
Visitor/Non-Patient Arrests
Arrest Team is responsible for all “arrests” within the hospital property or in the driveway immediately outside the hospital
Call NYP EMS (305-9999) or hospital transport (305-6267) to bring patients to the ER
Initial steps in a Code
Take a deep breath Introduce yourself as the code resident Buy yourself 15 seconds to relax by asking:
Are the pads on and is the board under the patient?
Initial steps in a Code
*CAB* Pulse? If NO compressions Rhythm? Pea/asystole vs VT/VF algorithm Shock? (only VT/VF) Access
Rapid assessment Primary survey Hs and Ts
Circulation C = Circulation
Pulse check Chest compressions
“Push hard and fast on the center of the chest” Minimize interruptions, allow recoil 30:2 synchronous, 100/min asynchronous
What is the current rhythm? Is IV access established? Does the patient need medications/volume resuscitation? Is the rhythm shockable?
D = Defibrillation Early defibrillation essential during “electrical phase”
Presenter
Presentation Notes
Circulation: Chest compressions are thought to be the most important element of cardiopulmonary resuscitation (CPR) [28-30]. The CPR mantra of the American Heart Association 2005 basic life support guidelines (2005 guidelines) is: "push hard and fast on the center of the chest." When performed at a rate of 100 compressions per minute, with a down-stroke of at least 38 mm, and allowing the chest to fully recoil between each down-stroke, coronary perfusion pressures are optimized, and return of spontaneous circulation (ROSC) is maximized [31,32]. Full chest recoil promotes lower intrathoracic pressures, resulting in enhanced cardiac preload and higher coronary perfusion pressures. Interruptions in compressions, no matter how brief, result in unacceptable declines in coronary perfusion pressures and worse outcomes. This was demonstrated in an animal study designed to simulate two approaches to single-rescuer resuscitation [33]. Thirty swine, in which ventricular fibrillation was induced, were randomly assigned to receive either continuous chest compressions or ventilation and chest compressions. In the latter group, compressions were halted for 16 seconds while ventilations were performed, replicating the time needed for a lone rescuer to provide a patient two breaths. Among swine receiving continuous compressions 80 percent (12/15) survived neurologically intact, versus 13 percent (2/15) in the compression with ventilation group. Although this study and several others support compression-only CPR, particularly in the early phases of arrest, there is not yet sufficient evidence to make this recommendation broadly. It is clear that clinicians should strive to minimize interruptions in compressions. Out-of-hospital observational investigations suggest that even brief pauses in chest compressions prior to energy delivery reduce the rate of successful defibrillation [34]. The revised 2005 advanced cardiac life support protocols also stress initiating advanced procedures (eg, advanced airway management, medication administration, and patient reassessment) in a manner that minimizes interruptions in chest compressions. Evidence suggests that manual compressions become less effective after a few minutes of consistent and uninterrupted performance, mostly due to operator fatigue and inexperience Defibrillation: The effectiveness of early defibrillation of patients with ventricular fibrillation (VF) and short "downtimes" is well supported by the resuscitation literature and encouraged in the American Heart Association 2005 basic life support guidelines (2005 guidelines) [25,27]. Since the publication of the 2000 guidelines, there have been significant changes in our understanding of the physiology of cardiac arrest and the technology used for defibrillation. Biphasic defibrillators, which measure impedance between the electrodes placed on the patient and adjust the energy delivered accordingly, successfully defibrillate approximately 85 percent of patients with the first shock [46-48]. The 2005 guidelines restrict their recommendations on energy delivery to 360 J when using a monophasic defibrillator [49]. We recommend that all defibrillations be delivered at the highest available energy in adults (generally 360 J for a monophasic defibrillator and 200 to 360 J for a biphasic defibrillator). In children, the guidelines continue to recommend 2 J/kg for the first defibrillation and 4 J/kg for subsequent doses with either monophasic or biphasic defibrillators. The 2005 guidelines recommend a single shock sequence when employing either a biphasic or monophasic defibrillator. We feel it is essential to minimize delays in the initiation of chest compressions caused by pulse checks or rhythm analysis. One observational study of 481 cases of cardiac arrest found that rhythm reanalysis, repeated shocks, and postshock pulse checks resulted on average in a 29-second delay in restarting chest compressions [50]. Furthermore, postshock pulse checks were of benefit in only 1 of 50 patients. R anterior chest, 3rd ICS, mid clavicular line
Airway, Breathing
A = Airway (use oral airways if needed) B = Breathing
Ventilations over 1 second TV sufficient for chest rise 30:2 with 1 breath q 5-6s Continuous with 1 breath every 6-8 s (8-10 breaths per
minute)
DO NOT OVERBAG!!!
Presenter
Presentation Notes
A: airway->head tilt-chin lift and assess for breath (look, listen, feel) and while person doing that the second person should be pulling bag-mask ventilatory kit out of the bag, hooking up to the oxygen tank attaching the mask and preparing to placeremember that with appropriately utilized bag-mask system with non-rebreathing reservoir we can deliver almost 100% O2. Breathing: importance of placement with correct hands. Uptodate ventilations: The American Heart Association 2005 basic life support guidelines (2005 guidelines) advise rescuers to deliver ventilations at a rate of 2 ventilations for each 30 compressions in the patient without an advanced airway, and one asynchronous ventilation 8 to 10 times per minute in the patient with an advanced airway (eg, endotracheal tube, extraglottic device). Asynchronous implies ventilations need not be coordinated with chest compressions. Ventilations should be delivered in as short a period as possible, not exceeding one second per breath, while avoiding excessive ventilatory force. Only enough tidal volume to confirm initial chest rise should be given. This approach promotes both prompt resumption of compressions and improved cardiocerebral perfusion. Care must be taken to avoid excessive ventilation, either through high rates or increased volumes. Positive pressure ventilation raises intrathoracic pressure which causes a decrease in venous return, pulmonary perfusion, cardiac output, and cerebral and coronary perfusion pressure. Studies in animal models have also shown that over-ventilation reduces defibrillation success rates and decreases overall survival [30,41-44]. (See "Basic airway management in adults"). Despite the risk of compromised perfusion, rescuers routinely over-ventilate patients. One study of prehospital resuscitation reported that average ventilation rates during cardiopulmonary resuscitation (CPR) were 30/minute, while a study of in-hospital CPR revealed ventilation rates of more than 20/minute [22,23]. Some studies have reported that chest-compression-only (CCO) CPR results in comparable outcomes when compared with standard (ie, ventilation and compression) CPR [28,45], and that lay person first responders are more likely to perform CPR when it did not require mouth-to-mouth ventilation. The 2005 guidelines, however, did not include CCO CPR because it was deemed that ventilation may be important for resuscitation of hypoxic arrest victims (eg, infants, children, and drug overdoses) and later (after the first few minutes) in the course of any arrest.
Next Steps:
Collateral history Chart Primary team
Labs and other vital signs Establishing disposition / transfer Miscellaneous (attending to family members,
contacting primary physician)
Post-Resuscitation Care
Further delineate and address contributing factors EKG, Labs Continue successful anti-arrhythmics as drips Continue pressors, if applicable Ensure proper airway, ventilation Plan disposition to unit Document! Notification Consider cooling, page b.8COOL
Termination of Resuscitation
“Decision must balance a respect for human dignity and clinical judgment”
Predictors of Unsuccessful Resuscitation
Unable to regain pulse after 10 minutes of ACLS
Prolonged ‘down-time’ prior to CPR initiation (unwitnessed)
Initial rhythm other than VT/VF Advanced age and severe comorbid diseases
Presenter
Presentation Notes
17% survival to discharge for all sudden cardiac arrests in hospital, much lower for PEA, poorest for asystole
Sample Arrest Note Location: (Floor/Room Number) Primary Service: (Include resident/attending, pagers if possible) Arrest call initiated by: Arrest witnessed: (Y/N) On telemetry: (Y/N) Condition and vitals upon arrival: Initial Rhythm: Description of resuscitation: (specify medications given, defibrillation attempts/response,
central line placement, advanced airway): -------- Event times -------- Time last seen responsive: Time arrest called: Time team arrived: Time of defibrillation (if indicated): Time pulse regained (if applicable): Impression: Disposition: Family Notified: (Y/N, specify relationship and telephone number) Attending Notified: (Y/N, specify)
Review
o Walk in the Room Pads Pulse Board Rhythm/Shock Access
Secondary Survey H’s/T’s
Breath Sounds Heart Sounds Review Labs Story
Review
ROSC EKG, Labs Placement Family Note
Throughout Watching Compressions Watching Airway Timing 2 minutes Feedback Loop with Team
ACLS Review
ACLS Review
Pulseless Arrest
Presenter
Presentation Notes
Antiarrythmic after second unsuccessful defib attempt Amio vs placebo (ARREST Trial) amio vs lidocaine (ALIVE trial)
Called to the bedside of a 48 year old man who feels lightheaded and has had a syncopal episode. The Zoll pads are in place and the defibrillator shows the following:
Case #3
What’s the rhythm? 3rd degree heart block
What are your treatment options? Remember DaTE:
Dopamine drip (Atropine) Transcutaneous pacing – leads must be attached Epinephrine drip
Case #3
To pace: Turn defibrillator dial to ‘Pace’ Set rate (70 is default) Turn up voltage until you see capture beats on
monitor Don’t forget sedation if patient is responsive
to pain!
Case #4
Case #4
Notified by telemetry that your 79 year old patient with HTN and atrial fibrillation is tachycardic to 190.
Patient is confused with a BP of 75/50 and a thready pulse.
Case #4
What’s the rhythm?
Case #4
Atrial fibrillation with RVR Stable or unstable?
Unstable: AMS, chest pain, hypotension
What’s next? Cardioversion:
Biphasic: 120J and up Don’t forget to **synchronize**
Case #5
Case #5
Called to bedside of 35 year old woman complaining of SOB and tongue swelling. Has PCN allergy and RN tells you she recently received ceftriaxone for PNA.
Vitals: BP 80/40, HR 120, O2Sat 87% Exam: appears warm and flushed, lungs with
Early intubation if hypoxemic, stridorous, or lingual swelling
Case #5
Medications: Epinephrine 0.3-0.5mg SC/IM (0.3-0.5mL of
1:1000 dilution) every 15-20min x3 doses May need IV infusion if poor tissue perfusion (2-
10mcg/min of 1:10,000) IVF and vasopressors for circulatory support Steroids: methylprednisolone 60mg IV Q6hr Antihistamines, Beta-agonists
Observe over 24 hours – biphasic anaphylaxis
Acute Intervention/Evaluation in the Service Building: 1. First Responder: Calls for help and delegates task of calling code teams 2. Code Team: Runs code and delegates tasks to others 3. Security: Brings Banyon Bag to the gym or specified area in the service
building when they hear code called in service building. 4. Call NYP EMS: (212)305-9999 GYM/ Staff 5. Other Staff: Available staff halts patient flow to area. Serves to make
calls and direct code team and EMS as they arrive on scene. 6. Code Team Arrives:
Assumes responsibility of patient on arrival code team to assist in seamless patient care until patient transported off the floor
Other staff remains available to Code team but may resume regular activities NYP EMS transport team called to transport patient to emergency department.
7. Patient Transported by NYP EMS to ED. EMS will notify ED of transport.
