FEATURE EMERGENCY MEDICINE
in lay people. Even with experienced providers, pulse check should not exceed 10 seconds, because if longer, the probable cause is absence of pulse. With delayed recognition of cardiac
arrest, chest compressions should proceed defibrillations. Long intervals of chest compression (1.5 – 3 minutes) were initially advocated. Two subsequent reports could not reproduce the benefit of prolonged CPR prior to the first shock. The 2005 guidelines introduced one
shock as an alternative to the three stacked shocks. Evidence supports the observation that the first shock is most likely to succeed, and subsequent attempts rarely succeed, delay chest compressions and allow biochemical decay in the myocardium. The 2005 guidelines recommended biphasic defibrillation over monophasic defibrillation. Subsequent evidence supports this recommendation. As a result, virtually all defibrillation and AED devices manufactured currently in the United States employ a biphasic waveform. The evidence does not support a consensus for the energy level for defibrillation, and the 2010 guidelines recommend using manufacturers guidelines with increasing to maximum levels after one failure of shock to achieve return of spontaneous circulation (ROSC) with evidence from the treatment of atrial fibrillation. The traditional three-shock sequence
(200, 300, 360) has been replaced by one single shock per cycle because of evidence that the success rate is higher on the first attempt. Delaying subsequent shocks until after chest compressions may allow the biochemical conditions within the myocardium to achieve a state where defibrillation can succeed, especially since acidosis interferes with defibrillation success. The quality of resuscitation should be confirmed by observation of the team leader. Recognition of fatigue as a cause of poor compressions requires that the team leader ensure that the person performing chest compressions should change every 3-5 minutes. Especially in the most morbid arrest situations (asystole, unresponsive PEA) the team leader should observe not only that compressions are being performed, but that they are being done correctly by palpating pulses during compressions. In addition, the team leader should be continuously looking for the cause of the arrest, because some causes
can be eliminated and conversely, without correcting these lesions, successful resuscitation is impossible.
The 2010 guidelines place emphasis on the quality of post arrest care, including optimization of hemodynamics, oxygenation, and active search for cause of cardiac arrest. Effect we care for patients with Acute Coronary Syndrome (ACS) and stroke places emphasis on protocol-driven care with time limits for interventions that improve outcomes.
«Basic cardiopulmonary resuscitation (CPR) resulted from a series of observations»
AIRWAY MANAGEMENT The 2010 guidelines eliminate the role of cricoid pressure in ventilation during cardiac arrest. Bag-mask ventilation is not recommended for single rescuers, but is regarded as a means to achieve ventilation without interrupting chest compressions. Supraglottic airways (LMA etc.) are advocated as a means of achieving advanced airway support without interrupting chest compressions. The role of endotracheal intubation is clearly favorable, but the timing is not. In an out-of-hospital setting, early intubation (<12 minutes) improved survival. In large registry reviews, early intubation did not increase the speed to achieve
ROSC, but was associated with improved survival. Passive oxygenation and delayed intubation improved neurological outcome in an out-of-hospital cardiac arrest setting. The converse is equally true. In the context of good bag-valve-mask ventilation, if intubation is attempted and requires more than a brief interval, it should be interrupted to restore
chest compressions. Colormetric CO2 detectors or preferably continuous wave form capnography is the preferred means of confirming and monitoring placement of endotracheal tubes. False negative findings can be associated with extended low perfusion, pulmonary embolism or extreme bronchospasm.
DRUG THERAPY DURING ACLS Vasopressor therapy is indicated after one shock and one cycle of chest compressions. Epinephrine (1 mg) remains first line, but vasopressin (40 units) can be substituted for the first or second dose (one time substitution). Amiodarone is regarded as the first line anti-arrhythmic. Lidocaine is only indicated if amiodarone is not available. Calcium remains contraindicated. Magnesium is only indicated for torsades with long QT interval. Drug administration should start with
peripheral venous access, unless central access is pre-existing. If peripheral access cannot be easily obtained, intraosseous access is the next choice before central access.
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