Do you follow current, best practice for BLS and ACLS? Some of the significant recommendations include:
• Chest compressions as the first step in BLS -- a "C-A-B" (circulation, airway, breathing) approach, instead of the previous "A-B-C" formulation;
• Quantitative waveform capnography to evaluate and monitor advanced airway placement and ventilation;
• Updated indications for medications, including intravenous (IV) epinephrine for pulseless electrical activity (PEA) and asystole, chronotropic agents for symptomatic or unstable bradycardia, and adenosine for the assessment and treatment of stable, monomorphic, wide-complex tachycardia;
• Urgent cardiac catheterization and percutaneous coronary intervention (PCI) in cardiac arrest survivors with ST-segment elevation myocardial infarction; and
• Postresuscitation measures, such as therapeutic hypothermia to improve neurologic outcomes, and maintaining appropriate oxygen saturation and blood glucose to prevent multiorgan dysfunction.
While you await the code team and equipment, which of the following should you perform first?
A. Open the patient's airway with a jaw-thrust or chin-tilt maneuver
B. Perform 2 rescue breaths, either mouth-to-mouth or using a mask with reservoir
C. Start chest compressions immediately at 100 compressions per minute
D. Pour ice on the patient to initiate hypothermic resuscitation
The patient has had a cardiac arrest from ventricular fibrillation (VF). Defibrillation is the most appropriate treatment, but while awaiting the necessary equipment you should initiate high-quality chest compressions rather than spending time on advanced airway maneuvers, according to the AHA recommendations.
The AHA recommends that a first responder to a code situation focus initially on calling for help, and then performing high-quality chest compressions. The new recommendations advise laypersons to focus on compression-only cardiopulmonary resuscitation (CPR). One reason for this change in emphasis is to encourage passersby, who may be reluctant to perform mouth-to-mouth breathing on a stranger, to provide high-quality CPR nevertheless.
For adult resuscitations in all settings, the appropriate rate of chest compressions is at least 100 compressions per minute. Initial responders should begin with a pulse assessment, and then proceed to 100-beat-per-minute compressions. Image courtesy of Wikimedia Commons.
Guidelines recommend use of quantitative waveform capnography to measure end-tidal carbon dioxide and provide easy confirmation of initial advanced airway placement. In addition, it provides continuous assessment of airway and ventilation. This can alert providers to otherwise undetected airway displacement during resuscitation and transport. Also, a sudden rise in end-tidal carbon dioxide during resuscitation is an independent marker of return of spontaneous circulation that can be noted without interrupting chest compressions.
CPR-assistance devices such as the impedance threshold device and load-distributing band CPR are not recommended, as they have not been shown to improve outcomes. Images courtesy of Wikimedia Commons
Which of the following should be administered to the patient?
C. Sodium bicarbonate
D. Calcium gluconate
E. All of the above
Give IV epinephrine at the dose for cardiac arrest. This is the mainstay of medical treatment for PEA and asystole (shown), though one should evaluate the patient quickly for any reversible causes. Although previous guidelines recommended atropine for routine treatment of PEA/asystole, it is no longer included in the PEA/asystole treatment algorithm.
You are able to get a palpable pulse after 4 minutes of ACLS. However, the patient's rhythm strip continues to show the same tracing, and systolic blood pressure is only 75 mm Hg.
Which of the following should be the next step?
A. Commence external pacing
B. Begin dopamine infusion
C. Begin epinephrine infusion
D. Any of the above is acceptable
External pacing or chronotropic agents (eg, dopamine, epinephrine) are all acceptable treatments for a symptomatic bradycardia. Atropine remains the initial treatment of choice for symptomatic or unstable bradycardia. However, IV infusion of chronotropic agents are now recommended as equally effective alternatives to transcutaneous pacing when atropine fails. Image courtesy of Wikimedia Commons.
Which of the following should you tell the students is indicated for this patient?
Other treatment options include amiodarone and electrical cardioversion. The indications for adenosine have been expanded. In the 2005 AHA guidelines, adenosine was recommended for stable, narrow-complex tachycardia consistent with supraventricular tachycardia, such as Wolff-Parkinson-White syndrome (shown). In the 2010 edition, adenosine is also indicated for the initial assessment and treatment of stable, monomorphic, wide-complex tachycardia with a regular rhythm. It should not be used in irregular tachycardia, such as atrial fibrillation.
While preparations are being made for placement of a temporary transvenous pacer, what should you emergently administer to the patient?
A. IV epinephrine bolus
B. IV dopamine drip
C. IV isoproterenol drip
D. IV atropine bolus
The guidelines call for use of atropine in patients with symptomatic bradycardia (heart rate approximately 43 bpm, with RR interval marked). While the new guidelines also recommend the use of IV chronotropic agents such as dopamine, epinephrine, and isoproterenol, atropine is still the first-line agent as it can be more quickly administered. In this particular case, given the hypotension, isoproterenol should not be used if an IV chronotropic agent is needed after atropine administration. Image courtesy of Eric Yang, MD
Chest compressions at a rate of 100 per minute, with minimal interruptions, are now recommended as the first step in resuscitation -- a C-A-B approach, instead of the previous A-B-C formulation. Cricoid pressure does not prevent aspiration and may delay advanced airway placement.