Guidelines for Emergency Cardiovascular Care

Aka: Guidelines for Emergency Cardiovascular Care

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II. Background

  1. Emergency Resuscitation has been significantly updated in 2000, 2005, 2010
  2. Broad evidence based changes
  3. Guidelines applied Internationally
  4. Applied across all Resuscitation courses
    1. Basic Life Support: Cardiopulmonary Resuscitation
    2. Advanced Cardiac Life Support
    3. Pediatric Advanced Life Support
  5. ACLS guidelines 2010 focuses on Cardiac Compressions as the first line intervention
    1. New Mnemonic is 'C-A-B'
    2. First-responders start compressions without a pulse check to minimize delays
    3. Cardiac Compressions should be hard and fast, interrupted only for <10 seconds for rhythm checks and Defibrillation
    4. Active Compression-Decompression devices (ACD-CPR, e.g. Lucas ) can be considered where available, however insufficient evidence in 2010

III. Protocol: Basic Life Support Changes

  1. No pulse check before starting CPR
    1. Laypersons inaccurately identify pulseless patient
  2. Automatic Electrical Defibrillator (AED)
    1. Public access Defibrillator emphasized
    2. Early Defibrillation critical for survival in arrest
  3. Bag Valve Mask Ventilation emphasized
    1. Pre-hospital providers should be skilled with BVM
    2. Endotracheal Intubation de-emphasized
    3. Tidal Volumes decreased to 50% (6-7 ml/kg)
  4. Chest Compressions
    1. Mainstay of Resuscitation
    2. All patients (child and adult) are compressed 100/min
    3. Cardiac Compressions should be hard and fast
    4. Ratio of Chest Compressions to ventilations
      1. One and two rescuer ratio are now both 30:2
      2. Exception: CPR in children by 2 health care providers is at a ratio of 15:2

IV. Protocol: Advanced Cardiac Resuscitation Changes

  1. Antiarrhythmic Drugs
    1. Bretylium no longer included in recommendations
    2. Amiodarone is preferable to Lidocaine usage
    3. Vasopressin is alternative to Epinephrine in Ventricular Fibrillation
      1. No Epinephrine used within 20 minutes of dose
      2. In practice, Vasopressin is often not available
    4. Sotalol is a new option for Ventricular Tachycardia
    5. Epinephrine
      1. High dose Epinephrine de-emphasized (may be harmful)
      2. Epinephrine is recommended in most of the ACLS cardiac guidelines 2010 (recommendation 2B)
        1. See Epinephrine regarding questions of efficacy in Cardiac Arrest since the 2010 ACLS guidelines
    6. New emphasis on use of one Antiarrhythmic
      1. Contrast to prior Antiarrhythmic soups
      2. Pro-arrhythmic effects increase with poly-drugs
  2. Acute Coronary Syndrome
    1. Pre-hospital 12 lead Electrocardiogram
    2. Pre-hospital triaging to Fibrinolytic candidate
    3. Early Fibrinolysis in Acute Myocardial Infarction
    4. Antiplatelet drugs (in addition to Aspirin 325 mg)
      1. Indications
        1. Patients likely to go to angiogram
        2. Unstable Angina
        3. Non-ST elevation MI
      2. Options (choose one per local catheter lab protocol)
        1. Clopidogrel 300 mg once or
        2. GP IIB IIIA Inhibitors
  3. Acute Ischemic Stroke (Code-Stroke)
    1. Indicated for patients meeting the NIH stroke score guidelines and no contraindications
    2. Intravenous tPA within 3 hours of symptom onset
    3. Do not use intravenous tPA beyond 3 hours of symptoms
  4. Endotracheal Intubation must be performed correctly
    1. Providers must be skilled (>6 intubations per year)
    2. Consider alternative airway management if not skilled
      1. Esophageal-tracheal Combitube (ETC)
      2. Laryngeal Mask Airway (LMA)
    3. Confirm endotracheal placement with End-Tidal CO2
    4. Use commercial tube holder
  5. Cocaine induced emergencies
    1. Ventricular Dysrhythmias
      1. Sodium Bicarbonate
      2. Alpha adrenergic blockers
    2. Acute Coronary Syndrome
      1. Benzodiazepines
      2. Nitrates
      3. Alpha adrenergic blockers
    3. Inappropriate Medications
      1. Non-selective Beta-Blockers (selective also)

V. References

  1. Cardiopulmonary Resuscitation Guidelines
    1. http://www.circulationaha.org
    2. (2010) Guidelines for CPR and ECC [PubMed]
    3. (2005) Circulation 112(Suppl 112):IV [PubMed]
    4. (2000) Circulation, 102(Suppl I):86-9 [PubMed]

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