1. ACLS Update Marisha Chilcott, MD CCRMC Emergency Department

2. Audience Survey Who has been certified in ACLS in last 3 years? Who was certified before then? Anyone ever give bystander CPR or CPR in the field? When was last time you participated in a Code Blue that had a really good outcome?

3. Audience Opinions Who thinks that CPR works? Can you actually save anyone? Would you initiate CPR as a bystander? Who has talked to Ann Lockhart or Elise Lewis about their experience on the reservoir run?

4. Grim Statistics for Code Blue Return of spontaneous circulation (ROSC) of about 40% - 60% Survival to hospital discharge of at most 15% Long term (3 year) survival ~40% OF the 15% that are discharged Long-term survival after successful in hospital cardiac arrest resuscitation American Heart Journal - Volume 153, Issue 5 (May 2007) Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of "limited" resuscitations. - Dumot JA - Arch Intern Med - 23-JUL-2001; 161(14): 1751- 8 (From NIH/NLM MEDLINE)

5. 38 YO Asian Male Homicide Detective Rides road bike total of 250 miles during week of 10/5/08 Goes for easy 3 mile training run w/ other officers 10/15/08 Stretches post run; reaching for the sky is the last thing he remembers until waking in the ER

6. What Happened While He was Asleep? Collapsed forward, striking head and face Pale, unresponsive, pulseless Companion officers start EXCELLENT CPR SRFD on scene in less than 3 minutes, defibrillator pads placed, rhythm checked…

8. V-Fib Arrest Shock w/ 120 Joules Continue EXCELLENT CPR (How do we know it was excellent?) Check pulse, check rhythm – carotid pulse present, sinus rhythm Transport to Santa Rosa Memorial Hospital In ER trauma bay, patient becomes alert, speaks coherently, and complains of being very sore

9. Epilogue Patient goes to cardiac catheter where he is diagnosed with severe 3 vessel disease Undergoes 3 Vessel CABG EP study demonstrates need for implantable defibrillator His friends take CPR and get their own cholesterol checked

10. Excellent CPR: Hard and Fast New ratio is 30:2 Chest compressions are more important than rescue breaths Compressions delivered at 100/minute (staying alive, staying alive, ah, ah, ah…) Ventilations 8-10/minute – slower than you think

11. Rhythm Check There is only one question… To shock, or not to shock V-Fib or pulseless V-Tach  SHOCK PEA or Asystole  MEDS AND CONTINUED CPR

12. NEW: KEEP DOING CPR! After delivering a shock, resume CPR for 2 minutes before checking rhythm again Simultaneously check for pulse Resume CPR while defibrillator charges, if need to shock again

13. Drugs Work NO MORE ET Tube administration IV access or IO access as soon as possible Epinephrine/Vasopressin Q3-5 minutes Amiodarone after Epi/Vasopressin; Lidocaine also OK, but now out of favor and not in field protocols

14. Vasopressin Indicated for V-Fib, V-Tach, PEA, Asystole; Give ONLY ONCE 40 Units IV/IO instead of 1 st or 2 nd dose of Epinephrine NOT for responsive (talking) patients with known CAD

15. Epinephrine First line drug for ALL pulseless rhythms 10 ml of 1:10,000 solution -- bolus 1 mg in 500 ml of NaCl or D5W @ 1microgram/min, titrate to effect

16. Amiodarone Give for V-Fib or pulseless V-Tach 1 st dose: 300 mg IV/IO 2 nd dose: 150 mg IV/IO Infuse: 0.5 mg/min x 18 hours

17. Atropine Symptomatic bradycardia or SLOW PEA PEA, Asystole: 1mg IV/IO Q3-5 min Bradycardia: 0.5mg IV/IOQ3-5 min, PRN Note that dose < 0.5mg can cause paradoxical bradycardia

18. 72 YO Caucasian Family Doctor Swimming, per his usual at the local pool Not feeling up to par, decides he should get out Wakes up in ICU What happened?

19. By stander CPR Oral surgeon swimming in same lane starts poor quality CPR 2 ER nurses, having breakfast @ poolside shove surgeon out of way and start excellent CPR Paramedics arrive, and deliver 2 shocks in field between continued CPR, establishing a line and intubating Transport to ER – CPR continuing

20. ER Code Blue On arrival to ER, rhythm remains VFib Shock in ER and Amiodarone bolus Rhythm converts to sinus Transferred to ICU Implantable defibrillator placed

21. CPR and Code Blue Success 2 weeks later, back in the office 5 years later, still swimming and seeing patients