ACLS AND MORE. Ryan Clark D.O. Medical Education Fellow University of Massachusetts Medical School Baystate Medical Center
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1 ACLS AND MORE Ryan Clark D.O. Medical Education Fellow University of Massachusetts Medical School Baystate Medical Center
2 FOCUS 1. The death of the pulse check 2. PEA and why you can stop memorizing the H s & Ts 3. What to do with epi: PARAMEDIC 2 4. Management of Refractory VF
3
4
5 DEATH OF THE PULSE CHECK How well do providers do with pulse checks? What are the AHA recommendations? What should we be doing?
6 1. END TIDAL CO2
7 2. ULTRASOUND: TTE Does ultrasound delay CPR? CASA algorithm
8 2. ULTRASOUND: TEE What are the advantages over TTE? How safe is it?
9 3. ARTERIAL LINE
10 PEA: why you can stop memorizing H s & T s
11 PSEUDO PEA Wu C et al. The Predictive Value of Bedside Ultrasound to Restore Spontaneous Circulation in Patients with Pulseless Electrical Activity: A Systematic Review and Meta-Analysis. PLos one Systematic review of 11 studies looking at use of ultrasound during PEA arrest and ROSC 777 patients total with 55% in pseudo PEA (PREM)
12 NOVEL APPROACH TO PEA
13 What should I be doing with Epi?
14 PARAMEDIC2 TRIAL
15 PARAMEDIC2 TRIAL 30 day survival: 3.2% (epi) vs 2.4% (placebo) OR unadjusted ( ) NNT- 112 Bystander CPR- 15 Defibrillation- 5 Survival to hospital D/C with favorable neurologic outcome: 2.2% (epi) vs. 1.2% (placebo) OR unadjusted- 1.1 ( )
16 WHEN MIGHT EPI BE USEFUL? 3 phase model of cardiac arrest 1. Electrical phase: 0-5 minutes 2. Circulatory phase: 5-15 minutes 3. Metabolic phase: 15+ minutes
17 Refractory Ventricular Fibrillation
18 ESMOLOL Driver, BE et al. Use of esmolol after failure of standard cardiopulmonary resuscitation to treat patients with refractory ventricular fibrillation. Resuscitation Oct;85(10): Lee YH, et al. Refractory ventricular fibrillation treated with esmolol. Resuscitation. 2016;107: mcg/kg bolus +/- gtt
19 DOUBLE SEQUENTIAL DEFIBRILLATION Theory: Transthoracic impedance Increased energy vector Logistics
20 Works Cited Eberle B, Dick WF, Schneider T, Wisser G, Doetsch S, Tzanova I. Checking the carotid pulse check: diagnostic accuracy of first responders in patients with and without a pulse. Resuscitation. 1996;33: Lapostolle F, Le Toumelin P, Agostinucci JM, Catineau J, Adnet F. Basic cardiac life support providers checking the carotid pulse: performance, degree of conviction, and influencing factors. Acad Emerg Med. 2004;11: Ahrens T et al. End-tidal carbon dioxide measurements as a prognostic indicator of outcome in cardiac arrest. Am J Crit Care 2001;10:391-8 Clattenburg EJ et al. Point-of-care ultrasound use in patients with cardiac arrest is associated with prolonged cardiopulmonary resuscitation pauses: a prospective cohort study. Resuscitation 2017 Clattenburg EJ, Wroe PC, Gardner K, Schultz C, Gelber J, Singh A, Nagdev A, Implementation of the Cardiac Arrest Sonographic Assessment (CASA) protocol for patients with cardiac arrest is associated with shorter CPR pulse checks, Resuscitation (2018). Blaivas M.: Transesophageal echocardiography during cardiopulmonary arrest in the emergency department. Resuscitation 2008; 78: pp
21 Works Cited ACEP Board of Directors : Guidelines for the use of transesophageal echocardiography (TEE) in the ED for cardiac arrest. Ann Emerg Med 2017; 70: pp Long, et al. Echocardiography in cardiac arrest: An emergency medicine review. American Journal of Emergency Medicine. 2018; 36: Meaney et al. Cardiopulmonary resuscitation quality: [corrected] improving cardiac resuscitation outcomes both inside and outside the hospital: a consensus statement from the American Heart Association. Circulation. 2013;128: Morgan R, Westmoreland C: Survey of junior hospital doctors attitudes to cardiopulmonary resuscitation. Postgrad Med J 2002;78: Wu C et al. The Predictive Value of Bedside Ultrasound to Restore Spontaneous Circulation in Patients with Pulseless Electrical Activity: A Systematic Review and Meta-Analysis. PLos one Littmann et al. A Simplified and Structured Teaching Tool for the Evaluation and management of Pulseless Electrical Activity. Med Princ Pract 2014
22 Works Cited Berman, et al. ECG patterns in early pulseless electrical activity-associations with aetiology and survival of in-hospital cardiac arrest. Resuscitation.2016;104:34-9. Perkins GD, Ji C, Deakin CD, et al. A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest. The New England journal of medicine PMID: Sagisaka, et al. Effects of repeated epinephrine administration and administer timing on witnessed out-of-hospital cardiac arrest. American Journal of Emergency Medicine. 2017; 35: Tanaka H., Takyu H., Sagisaka R., et al: Favorable neurological outcomes by early epinephrine administration within 19 minutes after EMS call for OHCA patients. Am J Emerg Med 2016; 34: pp Gordon A.E., Bobrow B.J., Chikani V., Sanders A.B., et al: The time dependent association of epi administration and survival from out-of hospital cardiac arrest. Resuscitation 2015; 96: pp
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