Suspect and promptly treat some specific reversible causes of arrhythmias even before confirmation of the diagnosis.
Know your H’s and T’s
- Hydrogen ion excess, that is acidosis
- Hyper or Hypokalaemia
- Thrombosis of coronary artery
- Thrombosis of pulmonary artery
- Toxins (two of which we’ll cover in a bit more detail)
- Tension pneumothorax
- Trauma is sometimes included here as well
HyperK: often asymptomatic,
ECG is not very sensitive, but might show:
- peaked Ts,
- wide QRS,
- flat Ps
- Hold ACEi and NSAIDs,
- stabilize heart with calcium,
- shift it into the cells with insulin and dextrose,
- try to get them to pee out the excess with furosemide.
- If this all fails, you need dialysis.
Digoxin Toxicity: if they take it, or accidentally could have eaten it, look for GI stuff, altered LoC, hyper K and new PVCs.
Get a level, but don’t wait for the result to treat with symptom support, charcoal if recent ingestion and Digibind if unstable.
Might look like:
- pressured speech,
- sympathomimetic symptoms.
treat presenting symptoms and watch for vasoconstrictive complications: stroke symptoms, cardiac symptoms.
Ensure adequate ventilation (ie. with a bag valve mask), and secure the airway in a timely manner. Know how and when to ensure adequate ventilation, (eg with BVM) and secure the airway in a timely manner
adequate ventilation looks like:
- in an adult, one breath, with just enough volume to see chest rise, every 5-6 seconds.
- breath should go in in one second
- this amounts to 10 resps per minute, but focus on the q5-6seconds as it is easier to conceptualize
- In the child: one breath, with just enough volume to see chest rise, every 3-4 seconds.
- The volume needed will be deceptively small, particularly if you only have an adult BVM, avoid barotrauma!
First step is always head-tilt-chin-lift, or jaw thrust, and an OPA.
ROSC without return of consciousness is a good indication for an advanced airway (LMA or ETT).
In patients requiring resuscitation, assess their circumstances (e.g., asystole, long code times, poor pre-code prognosis, living wills) to help you decide when to stop. (Avoid inappropriate resuscitation).
A few reasons why we might persist beyond this 20 minutes
- A young person with persistent VF until reversible factors have been managed
- Hypothermia. Remember, they aren’t dead until they’re warm and dead
- Asthma, because their reversible factor is the asthmatic breath stacking, or hyperinflation
- Toxicologic arrest, there are cases of full neuro recovery after 4 hours of CPR with these patients
- If thrombolytics have been given during CPR. He suggests continuing up to 2 hours after administration
- A pregnant women, until she has resuscitative caesarian section
- There are still reversible factors (Hs and Ts) to correct
Some reasons we might consider stopping from Dr. Nickson include:
- No ROSC during 20 minutes of resuscitation
- Preexisting chronic illness that would prevent meaningful recovery
- Eg. for someone with dementia who is in nursing home, disseminated cancer, etc
- Ideally there will be a loved one or SDM available who can attest to this, or knows their wishes
- Acute illness that would prevent recovery
- Such as 100% burns, other non-survivable associated injuries, a catastrophic TBI with no brainstem reflexes
- No response to ACLS seen after 20 minutes of efficient resusc and exhaustion of reversible causes
- Consider that if a patient’s initial rhythm on arrival to the ED is asystole/agonal, 20 minutes in this rhythm is considered not survivable
Note: Advanced age is NOT consider an independent predictor
In patients with serious medical problems or end-stage disease, discuss code status and end-of-life decisions (e.g., resuscitation, feeding tubes, level of treatment), and readdress these issues periodically.
Introduce the idea of advance care planning
as well as whether they would be interested in discussing it. “can we discuss where your health currently is, and where it might be going?”
Understanding: how much do they know about it and what do they want to know
- Goals: what are the most important things in their life, and what are some functions they would not want to live without.
- Fears: what are their biggest health fears, and fears in life in general
- Trade-offs: If you get sicker, what kind of medical interventions are you willing to endure for more time?
Decide: on a SDM “if you can’t speak for yourself, who would you want to do it?”
Document: identified SDM, principles of care identified, per local standards
There is another approach outline from UBC’s own Dr. Gallagher published in the CFP if you want another sourcehttps://www.cfp.ca/content/cfp/52/4/459.full.pdf
Another paper published in the Canadian Family Physician journal based on patient questionnaires showed that advance directives were not routinely addressed in the family practice. Most patients preferred to initiate the discussion of advance directives. However, patients who considered the subject extremely important wanted their family doctors to initiate the discussion. https://www.cfp.ca/content/61/4/353
Attend to family members (eg. with counselling, presence in the code room) during and after resuscitating a patient).
A NEJM article in 2013 [https://www.nejm.org/doi/full/10.1056/NEJMoa1203366] aimed to see the effects of family presence during CPR on both the family’s mental health and the CPR outcomes. This was pre-hospital in France. They found:
- No medical outcome differences were evident
- However, those family members that were present for the resuscitation effort had:
- Fewer occurrences of PTSD in the 90 days following
- Fewer symptoms of anxiety and depression compared to those who were not in the room
- No increase in medico-legal claims
Tintinalli’s offers a short table with practical advice for resuscitation scenarios(Tintinalli’s table 27-3):
- Assess patient’s wishes via either prior communications or advanced directive
- communicate with family and loved ones throughout the resuscitation
- allow family to be present during the efforts if feasible
- assess likely outcomes based on available evidence
- in conjunction with family and PCP, weight risks and benefits of efforts
- consider teaching procedures with consent of surrogate
- use multidisciplinary approach to family communications
- provide: spiritual, psychosocial and educational support to family and loved one throughout, and after termination of, resuscitative efforts
In paediatric resuscitation, use appropriate resources (eg. Baeslow tape, the patient’s weight) to determine the correct drug doses and tube sizes. In paediatric resuscitation, know what resources you can use to determine the correct drug dosing and tube sizes. As well as how to use these (there might not always be a nurse to cover your butt on this)
- PediStat – a paid application in which you can simply put in age or weight and get a ton of info including vitals appropriate as well as drug dosing.
- Lexicomp will also offer a per kg paediatric dosing section.
- Pedmed.org is another free online resource for pediatric dosing.
If no tape and need to know the tube size for a kiddo:
- Uncuffed endotracheal tube size = 4 + (Age / 4)
- Cuffed endotracheal tube size = 3.5 + (Age / 4)
Select the uncuffed tube for kids under 1 year old and a cuffed tube may be used after 3.5kg or 1 year of age.
Episode Three of the CCFP 105 topics podcast, ACLS Part II has launched! Have a listen, check the link if you prefer to read, and share with your friends 🙂Tweet