Ver el código de «Pulseless arrest»

{{Adult top}} [[pulseless arrest (peds)]].''
==Immediate==
[[File:ACLS-arrest.png|thumb|Algorithm for cardiac arrest (Adapted from ACLS 2010)]]
#Call for Help/activate Code Blue
#Start [[CPR]]
#Give oxygen
#Attach monitor/[[Defibrillation|defibrillator]]
#Rhythm shockable?

==V-Fib and Pulseless V-Tach (Shockable)==
*Shock as quickly as possible and resume CPR immediately after shocking
**Biphasic - 200J
**Monophasic - 360 J
*Give [[Epi]] 1mg if (shock + 2min of CPR) fails to convert the rhythm
*Give [[antiarrhythmic]] if (2nd shock + 2min of CPR) again fails
**1st line: [[Amiodarone]] 300mg IVP with repeat dose of 150mg as indicated
**2nd line: [[Lidocaine]] 2% 1-1.5mg/kg then 0.5-0.75mg/kg q5-10min
**Polymorphic V-tach: [[Magnesium]] 2g IV, followed by maintenance infusion

==Asystole and PEA (Non-Shockable)==
[[File:PEA.png|thumbnail]]
*[[epinephrine|Epi]] 1mg q3-5min

*Three major mechanisms of PEA (3 & 3 Rule)
#Severe Hypovolemia
#Obstruction
#*[[Tension pneumothorax]]
#*[[Pericardial effusion and tamponade|Cardiac tamponade]]
#*Massive [[Pulmonary embolism]]
#Pump Failure

===[[ACLS (Treatable Conditions)|Treatable ACLS Conditions]] (H's and T's)===
*Hypovolemia
*[[Hypoxemia]]
*Hydrogen ion (i.e. acidemia)
*[[Hypokalemia|Hypo]]/[[hyperkalemia]]
*[[Hypothermia]]
*[[Tension Pneumothorax]]
*[[Pericardial effusion and tamponade|Cardiac tamponade]]
*[[Toxicology (main)|Toxins]]
*[[Pulmonary embolism|Thrombosis, pulmonary]]
*[[Acute coronary syndrome (main)|Thrombosis, coronary]]

===PEA Evaluation by QRS===
Differential based on QRS being narrow or wide and aided by ultrasound
====QRS Narrow====
Mechanical RV Problem – Ultrasound should show hyperdynamic LV and potential cause
*[[Cardiac tamponade]]
*[[Tension pneumothorax]]
*[[Deterioration after intubation|Mechanical hyperinflation]]
*[[Pulmonary embolism]]
*[[ST-Elevation Myocardial Infarction (STEMI)|Acute MI with myocardial rupture]]
====QRS Widened====
Metabolic LV Problem – Ultrasound should show hypokinetic LV
*[[Hyperkalemia|Severe hyperkalemia]]
*Sodium-channel blocker toxicity (Ex. [[Tricyclic (TCA) toxicity]])
*Agonal rhythm
*[[ST-Elevation Myocardial Infarction (STEMI)|Acute MI with pump failure]]

==General==
*'''A''' (adjunct) - Place oropharyngeal airway
*'''B''' (breathing) - place on [[Ventilator]] to assure slow ventilation rate (attach to BVM mask)
**10-12 bpm, 500cc tidal volume, Fio2 100%
*'''C''' (compressions) - Switch out providers q pulse check; use metronome
**100-120 compressions/min
**Compress to a depth between 2-2.4 inches (5-6 cm)
**Allow full recoil between compressions
*'''D''' - defibrillation
**May be ok to shock during compressions if wearing gloves and using biphasic device<ref>Lloyd MS, Heeke B, Walter PF, and Langberg JJ. Hands-on defibrillation: an analysis of current flow through rescuers in direct contact with patients during biphasic external defibrillation. Circulation. 2008; 117:2510-2514.</ref>
**Precharge prior to pulse & rhythm check to increase overall compression time
*'''A''' (advanced airway)
**Use [[LMA]] (NOT ET tube - no break in compressions required)
*'''B''' (advanced breathing)
**Connect [[LMA]] to [[Ventilator]]
***Pressure control 20, RR 10, insp rate 1.5-2s
*'''C''' (advanced circulation)
**Place [[IO]] instead of central line
*'''D''' (differential)
**[[Ultrasound: In Shock and Hypotension]]

==Refractory Ventricular Fibrillation==
''A patient is considered refractory after ≥3 defib,  ≥3mg [[epinephrine]], and 300mg [[amiodarone]]''

''The following therapies are largely based on case studies or case series''

===[[Double simultaneous external defibrillation | Dual Sequential Defibrillation]]<ref>Hoch DH et al. Double Sequential External Shocks for Refractory Ventricular fibrillation. JACC 1994; 23: 1141 – 5.</ref> <ref>Bero M et al. Changing the management of refractory ventricular fibrillation: the consideration of earlier utilization of dual sequential defibrillation. Am J Emerg Med. 2019 May 29. pii: S0735-6757(19)30359-6. doi: 10.1016</ref> ===
#Continue high quality CPR. Consider using devices such as LUCAS CPR to avoid ineffective CPR due to rescuer fatigue
#Place a second set of defib pads in an alternative location on the chest (anterior/posterior and right upper chest/left lateral)
#Deliver 200J (or 360J if monophasic) simultaneously from both defibrillators
#Continue CPR

===Esmolol for Electrical Storm <ref>Driver BE, Debaty G, Plummer DW, et al. Use of esmolol after failure of standard cardiopulmonary resuscitation to treat patients with ventricular fibrillation. Resuscitation. 2014; 85(10):1337-1341.</ref><ref> Boehm KM. First report of survival in refractory ventricular fibrillation after dual-axis defibrillation and esmolol administration. West J Emerg Med. 2016 Nov;17(6):762-765. </ref><ref> Lee YH. Refractory ventricular fibrillation treated with esmolol. Resuscitation. 2016 Oct;107:150-5. doi: 10.1016. </ref>===

#Administer [[Esmolol]] bolus 500 mcg/kg IVP over 30 seconds (typical dose ranges 35-50 mg)
#If ROSC, initiate 50 mcg/kg/min infusion <ref> Al-Khatib SM. 2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac arrest. Circulation. 2018 Sep 25;138(13):e272-e391. doi: 10.1161 </ref>
#Deliver 200J (or 360J if monophasic) simultaneously from both defibrillators
#Continue CPR

Consider holding further epinephrine ([http://blog.wikem.org/the-current-state-of-refractory-vf/ The Current State of Refractory VF])

===[[Stellate Ganglion Nerve Block]] <ref>Margus, C, Correa, A, Cheung, W, et al. Stellate ganglion nerve block by point-of-care ultrasonography for treatment of refractory infarction-induced ventricular fibrillation. Ann Emerg Med. 2020;75(2):257–260. </ref>===
[[File:stellate ganglion block.png|thumb|The red star above denotes the intended target for lidocaine injection<ref>Margus, C, Correa, A, Cheung, W, et al. Stellate ganglion nerve block by point-of-care ultrasonography for treatment of refractory infarction-induced ventricular fibrillation. Ann Emerg Med. 2020;75(2):257–260.</ref>]]

#Place probe over left anterior neck
#Identify thyroid gland, carotid artery, C6/C7, longus colli muscle, and prevertebral fascia
#Advance needle to stellate ganglion which is deep to prevertebral fascia and superficial to longus colli muscle
#Inject 1-2 ml of 1% lidocaine without epinephrine and observe dissection of the muscle and fascia layers to confirm placement
#With placement confirmed, inject the rest of the anesthetic for a total of 10ml of volume

==Fibrinolytics==
===Dosing===
*Alteplase 0.6mg/kg IV push x1 given over 15 min (± heparin 5000 unit bolus), and then repeated 30 min after if still no ROSC<ref>Böttiger BW et al. Lancet 2001;357:1583-5.</ref>
**Heparin may be bolused with tPA or after ROSC obtained
**Max doses of 50mg may be as efficacious as 100mg
**Consider at least 20min of CPR after last dose of tPA before ending code

===Guidelines and Recommendations===
*ACLS 2010 does not yet recommend routine thrombolytics (Class III)
*CHEST 2012 and ACLS 2010 recommends in acute [[PE]] or high suspicion<ref>Kearon C et al. Chest 2012; 141 (2)(suppl):e419s-e494s.
Vanden Hoek TL et al. Circulation 2010; 122 (suppl):S829-S861.</ref>
**Class IIc and Class IIa, respectively
**2 hr infusion time recommended over long, 24hr (CHEST Class IIc)

==See Also==
*[[ACLS (Main)]]
*[[Double simultaneous external defibrillation]]
*[[Brain death]]
*[[Post cardiac arrest]]
*[[Pediatric pulseless arrest]]

==External Links==
*[http://ddxof.com/simplified-acls-algorithms/ DDxOf: Simplified ACLS Algorithms]
*[http://www.blog.numose.com/emed-basics/pulseless Numose EMed: The Pulseless Patient]

==References==
<references/>

[[Category:Cardiology]]
[[Category:Critical Care]]
[[Category:EMS]]