1. Cardiac Arrest/Post Arrest A Review of the Old and What is New? Dan O’Donnell 10/9/2007 Beech Grove Audit and Review

2. First Things First… Tell me your best Michigan Joke I will tell you my best ND joke –When is breakfast by the way? Go Cubbies

3. What are We Going to Cover This is not a review of ACLS –We all have that down cold right? Go over some intricate cardiac arrest runs Review DNRs and Living Wills Review Pediatric Cardiac Arrest –We can always use that review A word on IOs Rescue Airways What is new in arrest?

4. Case #1 You are called for “sick person” Upon arrival you find an approximately 55 y/o male lying on the ground with a bystander performing CPR –You see a hospital ID on the caregiver You arrive to find the patient is apneic and CPR is in progress

5. What Do We Do First? Feel for a pulse Perform CPR until defibrillator is attached Put on monitor

6. Ventricular Fibrillation or Pulselees VT Pulse Present –Support airway/breathing Pulse Absent –Intubate and IV –Epi 1mg IV or IO Defib within 30-60sec Amiodarone 300mg Drug-shock-CPR (2min)-Repeat –If no response to amiodarone Magnesium 2g IV

7. Now You Get You have a weak pulse What to do? Defibrillate at maximum settings Amiodarone 150mg IV over 10min if not given already

8. Good Job No pulse

9. PEA 5 Ts –Tension PTX –Tamponade –Thrombosis PE or MI –Tox 5 Hs –Hypovolemia –Hydrogen ions (acidosis) –Hypoxemia –Hypothermia –Hyperkalemia/Hypokal emia

10. Treatment for PEA CPR and BVM or Oxygenate Epinephrine 0.01mg/kg IV or IO Q 3-5 minutes Atropine as needed What if you picked them up from the HD center –CaCl 1gm slow IVP –Bicarb 100mEq IVP

11. Final Outcome

12. Next Case You are called for difficulty breathing You find a patient apneic and CPR is being done Your crew is addressing the cardiac issues You look and see

13. What is Your Plan of Attack for This Airway? We all have a plan Always have your plan

14. What do the Protocols Say? Open with chin-lift and jaw thrust Use OP or NP airway Suction as needed Assist with BVM If above measures are inadequate or risk of aspiration intubate or place non- visualized airway

15. How Many Shots do I get at the Tube? If unable to place ETT after 2 Attempts, place no visualized airway

16. When do I Cric? If basic airway management, non- visualized airways, and intubation are inadequate to sustain life How old can they be –8 yo –If under 8  needle cric

17. Next Case Called for cardiac arrest Upon arrival you find a family in hysterics saying that their grandmother isn’t breathing. She has terminal lung cancer and has a DNR that is somewhere? What to do?

18. DNRs Obey the DNR If the DNR cannot be found or produced begin resuscitative efforts in accordance with the appropriate protocols If there is any question regarding validity, resuscitative measures should be initiated. Contact the receiving facility for further orders. These DO NOT apply to living will

19. What About Hospice Contact the Hospice Nurse –Should be available 24/7 –Contact medical control as needed

20. Next Case Called for sick child Upon arrival find a 3 y/o child in mothers arms You remove the child and find she is pusleless and apneic Mom says she was “sick” this morning but started having trouble breathing about 30 minutes ago Child has no pulse and is not breathing

21. Pediatric Cardiac Arrest 2 Key Components 1. Oxygen and Ventilation is the MOST IMPORTANT factor in dealing with pediatric arrest 2. Broselow tape is an invaluable resource

22. Pediatric Arrest is run pretty much the same as Adults! With an emphasis on airway

23. Pediatric Facts Dose of Epinephrine? –0.01mg/kg Size of ETT? –Age/4+4 Joules to defibrillate –2J/Kg followed by 4J/KG Dose of Amiodarone –5mg/kg

24. A Word on IOs Indications –Can’t get an IV and: Cardiac arrest Profound hypovolemia with significant AMS Emergent need for an IV but veins are not immediately available If they are yelling and screaming because the IO hurts  they probably didn’t need it

25. Where are We Going with the IOs Tibial Tuberosity –Easy access  good in kids What about the Proximal Humerus? –Let gravity be your friend

26. What is New Possibly adding induced hypothermia for cardiac arrest survivors Start early  prehospital Will let you know soon.

27. Summary Remember your ACLS and beyond The LMA is looking to be a better tool than the combitube Respect the DNRs (or lack there of) Periodically review PALS Think humerus for your IOs GO CUBBIES –Next year maybe