Sense

React
Result !!
 TODAY

Review the latest changes in BLS & ACLS

Review of most common & important EKG Rhythms.

ACLS pulseless algorithm

Responsiveness
Primary A,B,C,D
 Primary A,B,C,D

2005 International Consensus Conference.Circulation 2005;112:III-17

Secondary A,B,C,D
 Secondary A,B,C,D

1
1 2
2

3
3
Secondary A,B,C,D
 Secondary A,B,C,D

1. Primary confirmation
1. Visualizes ETT goes through the
vocal cords
2. Observes vapors in the tube
3. Chest rise
4. 5 point auscultation of the chest
Secondary A,B,C,D
Secondary A,B,C,D
Secondary A,B,C,D

– Circulation
1. Establish IV access
2. Identify rhythm  monitor
3. Administer drugs
4. “appropriate for rhythm and
condition”
Simultaneous recording of aortic diastolic (red) and right atrial (yellow) pressures during CPR in
which 2 ventilations are delivered within 4-second time period

Ewy, G. A. Circulation 2005;111:2134-2142

Secondary A,B,C,D
Secondary A,B,C,D

– Deferential Diagnosis
– search for and treat identified
reversible causes
 Secondary A,B,C,D

6 H’s 6 T’s
– Hypovolemia – Tablets
– Hypoxia – Thrombosis “coronary”
– Hydrogen Ions “acidemia” – Thrombosis “Pulmonary”
– Hyperkalemia / – Tension pneumothorax
Hypokalemia – Tamponade, Cardiac
– Hypothermia – Trauma
– Hypoglycemia
– Checking the heart rhythm
– Checking the pulse
– inserting airway devices
– administration of drugs should be done
 Asystole

– “Flat line” protocol:

1. Check leads attachment.
2. Check leads selection
3. Power on/off
4. Check the gain
VF pulseless VT
 EKG review

1. Tachy vs. Brady

100 < rate < 60

Three questions:

1. Rate 1. Supraventricular vs.

2. QRS narrow or wide ventricular
3. P wave & PR interval

2. Source of rhythm &

blocks
 Medications

1. Why? (Actions)
2. When? (Indications)
3. How? (Dose)
4. Watch Out! (Precautions)
What is the most important medication in the
cardiac arrest?
O2
 How to give the medication
during CRP?

• I.V.
– Fast I.V. Bolus.
– 10 cc N.S. flush.
– Raise the arm.
– Use central venous
access if it available.
• E.T.T
– 2-3 times the I.V. dose
– Diluted 10cc N.S.
– 3-4 ambo-bag “to
diffuse the medication”
Which Meds can be given
through E.T.T?
 Which Meds can be given
through E.T.T?

NAVEL

Naloxon Atropine Vasopressin Epinephrine Lidocaine

 Epinephrine

• Action : α & β – adrenergic agonist activity

• Indication: all Pulseless rhythms.

• Dose:
• initial dose 1mg ( 10mL of 1:10 000 solution )
• Additional doses of 1mg every 3- 5 min
• No maximum dose.
• Precautions:
• PVC with digitalis.
• Hypertension
• Myocardial ischemia
 Vasopressin

• Survival higher in patients who had higher endogenous

vasopressin 1,2
• Action :
• Vasoconstriction by direct stimulation of the smooth
muscle V1 receptor.
• Combination with epinephrine resulted in decreased
cerebral perfusion 3
• increase coronary perfusion and cerebral oxygen
delivery during CPR 4
• Has no β – adrenergic activity.

• Indication: all Pulseless rhythms.

• Dose:
– Start with 40 units I.V. once.
– Don’t combine with epinephrine
 Vasopressin & Epinephrine

no statistically significant differences between

vasopressin and epinephrine
for death within 24 hrs or death before hospital discharge after a
successful CPR.

• There is thus insufficient evidence to support or refute the

use of vasopressin as an alternative to or in combination
with epinephrine in any cardiac arrest rhythm.
 Atropine

– Action : vagolytic action “SA and AV node”

– Indication: asystole & PEA with rhythm < 60/min .
– Dose:
– initial dose 1 mg
– Additional doses every 3-5 min
– max dose 3 mg/Kg
– Precautions:
– Myocardial ischemia
 Amiodarone

– Action : Na+, K+, Ca++ channel blocker and α & β Blocker.

– Indication: shock refractory VF/ Pulseless VT.
– Dose:
– initial dose 300 mg bolus
– Additional doses of 150 mg/kg
– Infusion dose of
– 1 mg/min for 6 Hr ( 360 mg ) then
– 0.5 mg/min for 18 Hr ( 540 mg )
– Maximum dose of 2.2 Gram / 24 Hr
– Precautions:
– Prolonged QT.
– Hypotension
– Negative Inotrope
 Lidocaine

– Action : suppress ventricular arrhythmia, ectopy and prolong

the refractory period.

– Indication: shock refractory VF/ Pulseless VT.

– Dose:
– initial dose 1-1.5 mg/Kg
– Additional doses of 0.5 – 0.75 mg/kg
– max dose 3 mg/Kg
– Infusion dose of 1-4 mg/min
– Precautions:
– Decreased LVH.
 Magnesium sulfate

• Indication: hypomagnesaemia & Torsades de pointes.

• Dose:
• initial dose 1-2 gram iv push over 2 min
• Infusion dose of 1 gram/hr
• Precautions:
• Hypotension.
• Renal failure.
 Sodium bicarbonate

• Indications
– Pre-existing metabolic acidosis,
–↑K
– Prolonged arrest > 10 min
• Dose:
– 1 mEq / Kg
• Precautions:
– ↑ Na / Hyperosmolality
– Metabolic alkalosis
– Unfavorable shift of O2-Hb dissociation curve
• Contraindication
– hypoxic lactic acidosis
 Medications

Medication 2005 changes

Epinephrine •No change

Vasopressin •All pulseless rhythms

•Can be used in E.T.T
Atropine •Maximum dose 3 mg

Amiodarone •No changes

Lidocaine •No changes

 References
• Aung K, Htay T. Vasopressin for cardiac arrest: a systematic review and
meta-analysis. Arch Intern Med 2005:17-24
• 2005 International Consensus Conference.Circulation 2005;112:III-29
• Linder KH, Strohmenger HU, Ensinger H, Hetzel WD, Ahnefeld FW,
Georgieff M, Stress hormone response during and after cardiopulmonary
resuscitation. Anesthesiology 1992;77:662-668
• Linder KH, Haak T, Keller A, Bothner U, Lurie KG, Release of
endogenous vasopressors during and after cardiopulmonary
resuscitation. Heart 1996;75:145-150
• Wenzel V, Linder KH, Augenstein S, Prengel AW, Strohmenger HU,
Vasopressin combined with epinephrine decreases cerebral perfusion
compared with vasopressin alone during cardiopulmonary resuscitation in
pigs. Stroke. 1998;29:1462-1467: discussion 1467-1468.
• Babar SI, Berg RA, Hilwig RW, Kern KB, Ewy GA Vasopressin versus
epinephrine during CPR: a randomized swine outcome study.
Resuscitation 1999; 185-192
• Linder KH, Dricks B, Strohmenger HU, Prengel AW, Lindner IM, Lurie
KG, Randomized comparison of epinephrine and vasopressin in patients
with out of hospital VF. Lancet. 1997; 349: 535-537
 References

• Kudenchuk PJet al. Amiodarone for resuscitation after out-of-hospital

cardiac arrest due to ventricular fibrillation. N Engl J Med. 1999:871-878
• Dorian P et al. Amiodarone as compared with lidocaine for shock-resistant
ventricular fibrillation. N Engl J Med 2002:884-90
• 2005 International Consensus Conference.Circulation 2005;112:III-17
• Paul Dorian, et al. NEJM 2002 Amiodarone as Compared with Lidocaine for
Shock-Resistant Ventricular Fibrillation
ACLS Pulseless Arrest Algorithm
Primary A,B,C,D
Primary A,B,C,D
Primary A,B,C,D
Primary A,B,C,D
Secondary A,B,C,D
Secondary A,B,C,D
Secondary A,B,C,D
Secondary A,B,C,D
Secondary A,B,C,D
Secondary A,B,C,D
• “Flat line” protocol:
– Check leads attachment.
– Check leads selection
– Power on/off
– Check the gain