Here’s my first lecture from SMACCgold: The New Intra-Arrest. It generated a bit of controversy amongst my critical care friends, so we’ll be discussing various parts in more detail in the coming weeks.
- Neurocritical Care Conference with Incredible Resus Speakers
- Please, please sign up for EMCrit CME
Links and References
- The Music to Code By Compilation
- Waveform ETCO2 is the only way to confirm tube placement during a code (Anaesthesia 2011;66:1183)
- Max Harry Weil’s Disease-a-Month on CPR
- Steve Smith has the references for PCI during arrest in this ECG Blog Post
- Vent Settings for Arrest: Volume AC, Vt 500, Peak Flow 30 lpm, RR 10, PEEP 0, FiO2 100%, Pressure limit 100 cm H20
- See the Slides Below for all the rest of the references
1 mg Epi and 20 IU Vasopressin Q3 minutes for 5 cycles, plus 40mg methylprednisolone for the 1st cycle. Hydrocortisone if in persistent shock
Journal Club Crit Care 2014;18:308
Why Epi and not Phenylephrine
From MH Weil’s Article Above:
Adrenergic agents with predominant a2 effect have been shown to be more effective as vasoconstrictor drugs, presumably because extrajunctional a2-receptors are more accessible to circulating catecholamines than postjunctional a1-receptors. This may explain why adrenergic amines that have predominant a1 actions such as methoxamine (Vasoxyl) and phenylephrine (Neo-Synephrine) are less effective than epinephrine after prolonged cardiac arrest.
LUCAS seems equivalent to excellent manual compressions (from ResusMe)
Cardiac Arrest: To the cath lab with ongoing chest compressions?
Steve Smith has a great post on the topic with a ton of evidence
Consider Dual-Shock for Non-Converting VF/VT
Charles Bruen has a great post with the evidence
Abstract on Esmolol presented at Social Media and Critical Care 2014, Gold Coast, Australia
Emergency Department Use of Esmolol in Refractory Ventricular Fibrillation
We describe the outcomes for patients receiving esmolol during refractory ventricular fibrillation (RVF) in the emergency department (ED).
A structured chart review in an urban academic ED of patients between January 2011 and March 2013 who received esmolol with an ED diagnosis of cardiac arrest (CA), ventricular fibrillation, or pulseless ventricular tachycardia, excluding patients who received esmolol before CA or after sustained return of spontaneous circulation (ROSC). Cardiac rhythms, CA management, timing of ROSC, and patient outcomes were recorded.
Six male patients met inclusion criteria; one was excluded because esmolol was administered after sustained ROSC. Four of five patients had out-of-hospital CA; all had automatic mechanical chest compressions delivered by a LUCAS™ device. All patients received repeated doses of epinephrine, amiodarone, lidocaine, sodium bicarbonate, as well as other adjunctive medications. Defibrillation was attempted many times for each patient prior to esmolol administration (median = 6.5, range 4-10). Some had temporary ROSC, but no patient had sustained ROSC after administration of these medications and defibrillation. All patients had a rhythm of VF at the time of esmolol administration. An esmolol loading dose and infusion of 500 mcg/kg and 50-100 mcg/kg/min, respectively, was subsequently administered to all patients. One patient with incessant VF achieved temporary ROSC and three others attained sustained ROSC after the administration of esmolol with repeat defibrillation; two survived to discharge with excellent neurologic outcomes.
Beta-blockade should be considered in all patients with RVF in the ED prior to cessation of resuscitative efforts.
Now on to the Podcast…