Medical Resuscitation for EM AI David Marcus, MD @EMIMDoc – EMIMDoc Medical Resuscitation for EM AI David Marcus, MD @EMIMDoc – EMIMDoc.org Residency Director, Combined EM/IM/CC Program

Goals Principle of running a good code Review of ACLS Review of relevant procedures and meds Recap Megacode

Running the Best Code Ever Know your stuff Avoid crowding Open, closed-loop, Communication There can only be one chef in the kitchen Teamwork and keeping everyone involved Code critique and Reflection

An 85 yr old M rolls in from Parker Jewish...

What do you do? Are you worried?

General appearance Frail, dry appearing elderly male Several amputated toes Tachypneic

Can you find any clues in the vitals? HR 100 BP 70/50 RR 30 O2 Sat 85% ORA FS 325 Can you find any clues in the vitals?

2 Liters Later... You have 2 good peripheral IV's, labs have been sent, lactate returns: Lactate 8.5 HR unchanged, BP down to 50's/palp What now boss?

Time to add the pressor Preferred: Norepinephrine (Levophed) - Incr HR, BP Phenylephrine (Neosynephrine) - Incr BP, may reflexively decr HR. Epinephrine - Incr HR, BP Dobutamine – Inotrope + Chronotrope. Minimal peripheral effect. Incr HR and C.O. Vasopressin - especially in sepsis. Fixed dose. Dopamine (out) – Less effective and more morbidity than others in sepsis.

Pressor Use Choose based on presumed pathology Titrate up or down to keep MAP around 60-65 mmHg May use multiple pressors at once

You start a pressor, and then this happens...

A funny beeping starts Pulse present, BP 90/60

Cardioversion/Defib SYNCHRONIZED – Anytime a pulse is present ASYNCHRONOUS/Defibrillation – if pulseless Biphasic device - 120 joules once, then 200 Continue compressions if pulseless until fully charged!

CLEAR!

Time to pull on your big boy/girl pants...

Asystole/PEA High quality compressions Shockable rhythm? Go for it! If not shockable: CPR x 2 min, Epi q3-5 min, AW? Check for rhythm every 2-3 min May use Vasopressin 40 units instead of Epi, once. If shockable (Vfib/Vtach): Amiodarone 300mg then 150mg after 2 shocks.

Tips for CPR Hard and fast, avoid interruptions 30:2, if intubated do simultaneous Review H's and T's

5 H's and T's Hypovolemia Tension PTX Hypoxia Tamponade Hydrogen ion (acidosis) Hypo-Hyper K Hypothermia Tension PTX Tamponade Toxins Thrombosis (PE) Thrombosis (CAD)

YOU DID IT!

Summary Brady Mgm't If asymptomatic, leave it alone If symptomatic: Atropine 0.5 mg push q3-5 min, total 3 mg If Atropine doesn't work - DA or Epi gtt Consider TCP or TVP

Post-Arrest Care... Follow BP, HR and Sat closely Make sure you still have enough ppl at bedside Titrate drips as needed: pressors, ?ABx, ?Antiarrhythmics Sedation

Post-Arrest Care... Exotica Hypothermia protocol eCPR/ECMO

The General Approach Always start with general impression Delegate! Stand in one place (foot of bed) Good leader = Good listener At the end - reflect/critique, with entire team

Recap What to do with: Hypotension Hypoxia Bradycardia PEA/Asystole (H's and T's) Tachyarrhythmias

Procedures AW management Central venous access Defib/Cardioversion

Medications Epi Atropine Vasopressin Calcium Lidocaine Amiodarone Antibiotics Pressors Bicarbonate Insulin/D50

Pt presents with HR 20 and AMS, you should: Give Atropine IV Start compressions Monitor Transcutaneous pacing Transvenous pacing

Pt in volume refractory shock, you should: Give 2 more liters of saline Use US to assess fluid status Start a pressor Trendelenburg Call ICU

Pt p/w HR 150 and irregular, BP 70/40 you should: Try a calcium channel blocker, like Diltiazem Hit the patient's sternum with your fist Synchronized cardioversion Asynchronous cardioversion Give IV fluids Call cardiology

CPR in progress x 10 min, pt has received Epi 1 mg x 1, still PEA on monitor. You should: Stop for a pulse check Give another round of Epi Review the H's and the T's Start a pressor Give Atropine Stop CPR

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