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

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

4. 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

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

6. What do you do? Are you worried?

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

8. 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?

11. 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?

12. 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.

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

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

15. A funny beeping starts
Pulse present, BP 90/60

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

18. CLEAR!

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

21. 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.

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

23. 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)

24. YOU DID IT!

25. 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

26. 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

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

28. 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

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

30. Procedures
AW management
Central venous access
Defib/Cardioversion

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

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

34. 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

35. 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

36. 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

37. Slideset will be available at theEMpulse.org/studentportal
Questions?
Slideset will be available at theEMpulse.org/studentportal