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.
Best Article of Arrest Physiology
Physio of Cardiopulmonary Resuscitation (Anesth and Analg 2016;122(3):767)
- Please, please sign up for EMCrit CME
Links and References
- See this EMCrit Podcast on Hemodynamic Dosing of EPI
- 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
- Eliminate the Peri-Shock Pause–it is crucial (Resuscitation. 2014 Mar;85(3):336-42.)
- Precharging the Defib helps eliminate the pause (10.1016/j.resuscitation.2021.09.037)
- Pulse Checks are Stupid and Likely you are Feeling over a Vein1
- 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.
Note: To do hemodynamic dosing of vasopressors properly, it is imperative you read this post (choosing the correct DBP); you should also probably listen to that podcast.
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
But it may fry your defib and you won't even know it2
Update: Association between Intra-arrest venous gas and survival
Critical Care volume 21, Article number: 322 (2017)