7 ACLS part 5 Cardiac arrest: VF/ Pulseless VT

endotracheal route

IV and IO administration routes are preferred over the ET administration route; when considering adminsitraiton of drugs via the ET route during CPR, keep these concepts in mind: the optimal dose of most drugs given by the ET route is unknown The typical dose of drugs administered via the ET route is 2 to 2.5 times the IV route CPR will need to be stopped transiently so drug does not regurgitate up the ET tube studies demonstrate that epinephrine, vasopressin, and lidocaine are absorbed into the circulatory system after adminsitration via the ET route; when giving drugs via the ET route, dilute the dose in 5 to 10 mL of sterile water or normal saline; inject the drug directly into the ET tube

magnesium sulfate

IV magnesium may terminate or prevent recurrent torsades de pointes in patients who have a prlonged QT interval during normal sinus rhythm; when VF/ pulseless VT cardiac arrest is associated with torsades de pointes, give magnesium sulfate at a loading dose of 1 to 2 g IV/IO diluted in 10 mL (e.g. D5w, normal saline) given over 5 to 20 minutes; if a prearrest 12-lead ECG is available for review, check the QT interval for prolongation remember that pulseless VT is treated with an immediate high-energy shock, whereas magnesium is an adjunctive agent used to prevent recurrent or treat persistent VT associated with torsades de pointes magnesium sulfate is also indicated for patients with known or suspected low serum magnesium, such as patients with alcoholism or other conditions associated with malnutrition or hypomagnesmic states; for patients in refractory VF/ pulseless VT, check the patient's history, if available, for one of these conditions that suggests hte presence of a reversible electrolyte abnormality

rhythms for VF/ pulseless VT

VF VT ECG artifact that looks like VF new LBBB

coronary perfusion pressure

____________ is aortic relaxation (diastolic) pressure minus right atrial relaxation (diastolic) pressure; during CPR, _______________ correlates with both myocardial blood flow and ROSC; in 1 human study, ROSC did not occur unless a CPP 15 mmHg or greater was achieved during CPR

cardiac arrest priorities

_______________ are high-quality CPR and early defibriliation; insertion of an advanced airway and drug administration are of secondary importance; no drug given during cardiac arrest has been studied adequately to show improved survival to hospital discharge or improved neurologic function after cardiac arrest; historically in ACLS, providers have administered drugs either via the IV or ET route; ET absorption of drugs is poor and optimal drug dosing is not known; for this reason, the IV or IO routes are preferred

amiodarone

________________ 300 mg/ IV or IO bolus, then consider an additional 150 mg IV/IO once amiodarone is considered a class III antiarrhytmic drug, but it possesses electrophysiological characteristics of the other classes; amiodarone blocks the sodium channels at rapid pacing frequencies (class I effect) and exerts a noncompetitive antisympathetic action class II effect; one of the main effects of prolonged amiodarone administration is lengthening of the cardiac action potential (Class III effects) if amiodarone is not available, providers may administer lidocaine

naloxone

________________ is a potent opioid receptor antagonist in the brain, spinal cord, and GI system; naloxone has an excellet safety profile and can rapidly reverse CNS and reapiratory depression in a patient with an opioid-associated resuscitative emergency; basedon on the resucer's training and clinical circumstance, naloxone can be administered intravenously, intramuscularly, intranasally, or subcutaneously, nebulized for inhalation, or instilled into the bronchial tree via ET tube

chest compression fraction

________________ is the production of time during cardiac arrest resuscitation when chest compressions are performed; CCF should be as high as possible; at least 60% and ideally greater than 80%; data suggest lower CCF is associated with decreased ROSC and survival to hospital disadvantages

lidocaine

_________________ 1 to 1.5 mg/kg IV/IO first dose then .5 to .75 mg/kg IV/IO at 5 to 10 minute intervals, to a maximum dose of 3 mg/ kg lidocaine suppresses automaticaticity of conduction tissue in the heart, by increasing the electrical stimulation threshold of the ventricle, His-Purkinje syystem, and spontaneous depolarization of the ventricles during diastole by a direct action on the tissues; lidocaine blocks permeability of the neuronal membrane to sodium ions, which resutls in inhibition of depolarization and the blockage of conduction

defibrillation

_________________ does not restart the heart; ________________ stuns the heart and briefly terminates all electrical activity, including VF and pVT; if the heart is viable, its normal pacemakers may eventually resume electrical activity (return of spontaneous rhythm) that ultimately results in a perfusing rhythm (ROSC) in the first minutes after successful defibrillation, however, any spontaneous rhythm is typically slow and may not create pulses or adequate perfusion; the patient needs CPR (beginning with chest compressions) for several minutes until adequate heart function resumes; moreover, not all shocks will lead to successful defibrillation; this is why it is important to resume high-quality CPR, beginning with chest compression immediately after a shock

vasopressors

_________________ optimize cardiac output and blood pressure; the ________________ used during cardiac arrest is: epinephrine: 1 mg IV/IO (repeat every 3 to 5 minutes) if IV/IO access cannot be established or is delayed, give epinephrine 2 to 2.5 mg diluted in 5 to 10 mL of sterile water or normal saline and injected directly into the ET tube; remember, the ET route of drug administration results in variable and unpredictable drug absorption and blood levels

drugs for VF/ Pulseless VT

___________________ include: epineprhine norepinephrine amiodarone lidocaine magnesium sulfate dopamine oxygen other medications, depending on the cause of the VT/pulseless VT arrest

extracorpreal membrane oxygenation

____________________ CPR refers to venoarterial extracorpreal membrane oxygenation during cardiac arrest, including extracorporeal membrane oxygenation and cardiopulmonary bypass; these techniques requrie adequate vascular access and specialized equipment; the use of ECPR may allow providers additional time to treat reversible underlying causes of cardiac arrest (e.g. acute coronary artery occlusion, PE, refractory VF, profound hypothermia, cardiac injury, myocarditis, cardiomyopathy, congestive heart failure, drug intoxication) or serve as a bridge for LV assist device implanatation or cardiac transplantation

vasopressin

____________________ has been removed from the 2015 AHA guidelines update for CPR and ECC the 2015 AHA guideliens states that _____________ offers no advantage as a substitute for epinephrine in cardiac arrest; as such, it has been removed from the 2015 updated algorithm

lidocaine

____________________ lidocaine is an alternative antiarrhythmic of long-standing and widespread familiarity; however, it has no provn short-term or long-term efficacy in cardiac arrest; providers may consider giving lidocaine when amiodarone is not avaialble the inital lidocaine dose is 1 to 1.5 mg/kg IV/ IO; repeat if indicated at 0.5 to .75 mg/kg IV/IO over 5 to 10 minute intervals to a maximum of 3 mg/ kg if no IV/IO access is avaliable, the dose for ET administration is 2 to 4 mg/Kg

shortening the interval

_____________________ between the last compression and the shock by even a few seconds can improve shock success (defibrilation and ROSC); thus, it is reasonable for healthcare providerse to practice efficient coordination between CPR and defibrillation to minimize the hands-off interval between stopping compressions and administering the shock for example, after verifying a shockable rhythm and initiating the charging sequence on the defibrillator, another provider should resume chest compressiosn and continue until the defibrillator is fully charged; the defibrillator ouperator should deliver the shock as soon as the compressor removes his or her hands from the patient's chest and all providers are clear of contact with the patient uses of a multimodal defibrillator in manual mode may reduce the duration of chest compression interruptionrequried for thythm analysis compaerd with automatic mode but could increase the frequency of inappropriate shock; individuals who are not comfortable interpretiting cardiac rhythms can continue to use an AED for an AED follow the device's prompts or know your device-specific manufacturer's recommendations it is important that healthcare providers be knowledgable of how their defibrillator operates, and if possible, limit pauses in chest compressions to rhythm analysis and shock delivery

quality improvement

_____________________ relies on valid assessment of resuscitation performance and outcome; the Ustein guidelines provide guidance for core performance measures, including: -rate of bystander CPR -time to defibrilation -survival to hospital discharge it is important to share information among all links in the system of care, including: -dispatch records -EMS patient care record -Hospital records

peripheral IV

a ________________ is preferred for drug and fluid adminsitration unless central line access is already available; central line access is not necessary during most resuscitation attempts; central line access may cause interruptions in CPR and complications during insertion, including vascular laceration, hematomas, and bleeding; insertion of a central line in a noncompressible vessel is a relative (not absolute) contraindication to fibrinolytic therapy in patients with ACS establishing a ___________________ does not require interruption of CPR; drugs, however, typically require 1 to 2 minute sto reach the central circulation when given by the central IV route; if a drug is given by the peripheral veneous route, admniister it as follows: give teh drug by bolus injection unless otherwise specified follow with a 20 mL bolus of IV fluid elevate the exteremity for about 10 to 20 seconds to facilitate delivery of the drug to the central circulation

high-quality CPR

a team member should continue to perform ________________ until the defibrilator arrives and is attached to the patient; the team leader assigns roles and responsibilities and organizes interventions to minimize interruptiosn in chest compressions; this accomplishes the most critical interventions for VF or pulseless VT: CPR with minimal interruptions in chest compressions and defibrilation during the first few minutes of arrest

epinephrine

although healthcare providers have used _______________ for years in resuscitation, few studies have been conducted to address the question of whether it improves outcome in humans; ________________ administration improves ROSC and hospital admission rates; however, large studies have not been conducted to evaluate whether survival is improved; becuase there are no large studies to confirm longer-term outcomes, we rely on the positive short-term effects of increased ROSC and increased hospital admission to support the use in cardiac arrest; no studies demonstrate improved rates of survival to hospital discharge or neurologic outcome when comparing standard epinephrine doses with inital high-dose or escalating-dose epineprhine; therefore, the AHA does not recommend the routine use of high-dose or escalating doses of epineprhine epinephrine is though to stimulate adenergic receptors, producing vasoconstriciton, increasing blood pressure and heart rate, and improving perfusion pressure to the brain and heart repeat epinephrine 1 mg IV/IO every 3 to 5 minutes during cardiac event Remember follow each dose given by peripheral injection with a 20 mL flush of IV fluid and elevate the extremity above the level of hte heart for 10 to 20 seconds

high-quality CPR

another characteristic of _________________ is minimal interruptions in chest compressions; studies demonstrate that healthcare providers interrupt compression far too often and for too long, in some cases spending 25-50% of a resuscitation attempt without delivering chest compressions

antiarrhythmic agents

as with vasopressors, research is still lacking on the effect of routine administration of ____________________ during human cardiac arrest and survival to hospital discharge; amiodarone, howeevr, has been shown to increase short-term survival to hospital admission when compared wiht placebo or lidocaine

VF/pVT

because many patients with sudden cardiac arrest demonstrate _____________ at some point in their arrest, it is likely that ACLS providers will frequently follow the left side of the Cardiac Arrest Algorithm; rapid treatment of VF according to this sequence is the best approach to restoring spontaneous circulation; pulseless VT is included in the algorithm because it is treated as VF; VF and pulseless VT require CPR until a defibrilator is available; both are treated with high-energy unsynchronized shocks

rhythm check

conduct a ______________ after 2 minutes of CPR; be careful to minimize interruptions in chest compressions; interruption in compressions to conduct a rhythm analysis should not exceed 10 seconds; if a nonshockable rhythm is present and the rhythm is organized, a team member should try to palpate a pulse; if there is any doubt about the presence of a pulse, immediately resume CPR if the rhythm check is organized and there is a palpable pulse, proceed ot post-cardiac arrest care if the rhythm check reveals a nonshockable rhythm and there is no pulse, proceed along the asystole/PEA pathway on the right side of the Cardiac Arrest Algorithm if the rhythm check reveals a shockable rhythm, resume chest compressions if indicated while the defibrilator is charging; the team leader is responsible for team safety while compressions are being performed and the defibilator is charging

rhythm check

conduct a _______________ after 2 minutes of CPR; be careful to minimize interruptions in chest compressions the pause in chest compressions to check the rhythm should not exceed 10 seconds if a nonshockable rhythm is present and the rhythm is organized, a team member should try to palpate a pulse; if there is any doubt about the presence of a pulse, immediately resume CPR

amiodarone

consider amiodarone for treatment of VF or pulseless VT unresponsive to shock delivery, CPR, and a vasopressor amiodarone is a complex drug that affects sodium, potassium, and calcium channels; it also has B-adenergic and B-adenergic blocking properties During cardiac arrest, consider amiodarone 300 mg IV/IO push for hte first dose; if VF/pulseless VT persists, consider giving a second dose of 150 mg IV/IO in 3 to 5 minutes

systematically reviewed

data should be __________________ and compared internally to prior performance and externally to similar systems; existing registeries can facilitate this benchmarking effort; examples include the: CARES for OHCA Get with the guidelines-resuscitation program for IHCA

treatment of VF/pVT in hypothermia

defibrillation is appropriate for the cardiac arrest patient in _______________ who has severe hypothermia and a body temperature of less than 30 C (86 F); if the patient does not respond to the inital shock, it is reasonable to perform additional defibrillation attempts according to the usual BLS guidelines while engaging in active rewarming; the hypotehrmic patietn may have a reduced rate of drug metabolism, raising concern that drug levels may accumulate to toxic levels with standard dosing regimens; although the evidence does not support the use of antiarrhythmic drug therapy in hypothermic patients in cardiac arrest, it is reasonable to consider administration of a vasopressor according ot the standard ACLS algorithm concurrent with rewarming strategies ACLS treatment of the patient with severe hypothermia in cardiac arrest in the hospital should be aimed at rapid core rewarming for patients in cardiac arrest with moderate hypothermia (30 to 34 C; 86 to 93 F) start CPR, attempt defibrillation, give medications spaced at longer intervals, and, if in hospital, provide active core rewarming

intraosseous route

drugs and fluids during resuscitation can be delivered safely and effectively via the IO route if IV access is not available; important poitns about IO access are: IO access can be established in all age groups IO access often can be achieved in 30 to 60 seconds the IO route of administration is preferred over the ET route and may be easier to establish in cardiac arrest any ACLS drug or fluid that is administered IV can be given IO IO cannulation provides access to noncollapsable marrow venosu plexus, which serves as a rapid, safe, and reliable route for administraiton of drugs, crystalloids, colloids, and blood during resuscitation; the technique uses a rigid needle, preferably a specially designed IO or bone marrow needle from an IO access kit

persistent VF/ pulseless VT

for ____________________, give 1 shock and resume CPR immediately for 2 minutes after the shock Immediately after the shock, resume CPR, beginning with chest compressions; give 2 minutes of CPR; when IV/IO access is available, give epinephrine during CPR after the second shock as follows: epinephrine 1 mg IV/IO- repeat every 3 to 5 minutes note: if additional team members are available, they should anticipate the need for drugs and prepare them in advance epineprhine hydrochloride is used during resuscitation primarily for its B-adrenergic effects, ie, vasoconstriction; basoconstriction increases cerebral and coronary blood flow during CPR by increasing mean arterial pressure and aortic diastolic pressure; in previous studies, escalating and high-dose epinephrine did not improve survival to discharge or neurologic outcome after resuscitation from cardiac arrest no known vasopressor (epineprhine) increases survival from ___________________; because these medications can improve aortic diastolic blood pressure, coronary artery perfusion pressure, and the rate of ROSC, the AHA continues to recommend their use

minute

for every ______________ that passes between collapse and defibirllation, the chance of survival from a witnessed VF sudden cardiac arrest declines by 7% to 10% per minute if no bystander CPR is provided; when bystandards perform CPR, the decline averages 3 to 4% per minute; CPR performed early can double or triple survival from witnessed sudden cardiac arrest at most defibrillation intervals

shock and arrhythmias

give 1 shock and resume CPR beginning with chest compressiosn for 2 minutes immediately after the shock; healthcare providers may consider giving antiarrhythmic drugs, either before or after the shock; research is still lacking on the effect of antiarrhythmic drugs given during cardiac arrest on survival to hospital discharge; if administered, amiodarone is the first-line antiarrhythmic agent given in cariac arrest because it has been clinically demonstrated that it improves the rate of ROSC and hospital admission in adults with refractory VF/ Pulseless VT

fluid administration

healthcare providers should titrate fluid administration and vasoactive or inotropic agents as needed to optimize blood pressure, cardiac output, and systemic perfusion; the optimal post-cardiac arrest blood pressure remains unknown; however, a mean arterial pressure 65 mmHg or greater is a reasonable goal; in hypovolemic patients, the ECF volume is typically restored with normal saline or lactated ringer's solution; avoid D5W bevause it will reduce serum sodium too rapidly; serum electrolytes should be appropriately monintored

central venous oxygen saturation

if oxygen consumption, arterial oxygen saturation, and hemoglobin are constant, changes in SCVO2 reflect changes in oxygen delivery due to changes in cardiac output; SCVO2 can be measured continuously by using oximetric tipped central veous catheters placed in hte superior vena cava or pulmonary artery; normal range is 60 to 80% if the SCVO2 is less than 30%, it is reasonable to try to improve chest compressiosn and vasopressor therapy

resume CPR

immediately _________________, beginning with chest compressions do not perform a rhythm or pulse check at this point unless the patient is showing signs of life or advanced monitoring indicates ROSC establish IV/ IO access

opioid overdose

in the US in 2013, 16,235 people died of prescription opioid toxicity, and an additional 8256 died of heroin overdose; in the US in 2012, opioid overdose became the leading cause of unintentional injurious death in people aged 25 to 60 years, accounting for more deaths than motor vehicle collisions; a majority of these deaths are associated with prescription opioids; statistcs are similar in canada

coronary perfusion pressure or arterial relaxation pressure

increased CPP correlates with both myocardial blood flow and ROSC; a reasonable surrogate for CPP during CPR is arterial relaxation (diastolic) pressure, which can be measured by using an intra-arterial catheter if hte arterial relaxation pressure is less than 20 mmHg, it is reasonable to try to improve chest compressions and vasopressor therapy

opioid overdose

isolated opioid toxicity is associated with central nervous system (CNS) and respiratory depression that can progress to respiratory and cardiac arrest; most opioid deaths involve the coingestion of multiple drugs or medical and mental health comorbidities; in addition, methadone and propoxyphene can cause torsades de pointes, and cardiotoxicity has been reported with other opioids; except in specific clinical settings (e.g. unintended opioid overdose during a medical procedures), rescuers cannot be certain that the patient's clinical condition is due to opioid-induced CNS and respiratory depression toxicity alone

AED programs

lay rescuer _______________ increase the likelihood of early CPR and attempted defibrillation; this helps shorten the time between collapse and defibrillation for a greater number of patients with sudden cardiac arrest

rhythm check

perform a _________________- preferably during rhythm analysis- only if an organized rhythm is present; if the rhythm is organized and there is a palpable pulse, proceed to post-cardiac arrest care if the rhythm check reveals a nonshockable rhythm and there is no pulse, proceed along the asystole/PEA pathway on the right side of the Cardiac Arrest Algorithm if the rhythm check reveals a shockable rhythm, give 1 shock and resume CPR immediately for 2 minutes after the shock

magnesium sulfate

providers should consider __________________ for torsades de pointes associated with a long QT interval; ________________ for torsades de pointes, loading dose 1 to 2 g IV/IO diluted in 10 mL (e.g. D5W, normal saline) given as IV/IO bolus, typically over 5 to 20 minutes magnesium can be classified as a sodium/potassium pump agonist magnesium has several electrophysiological effects, including suppression of atrial L and T type calcium channels and ventricualr after depolarizations routine administration of ________________ in cardiac arrest is not recommended unltess torsades de pontes is present

measuring and benchmarking

simply ______________________ care can positively influence outcome; however, ongoing review and interpretation are necessary to identify areas for improvement, such as: citizen awareness citizen and healthcare professional education and training increassed bystander CPR resposne rates improved CPR performance shortened time to defibrilation

manual defibilator

the AHA does not recommend continued use of an AED or automatic mode when a _________________ is available and the provider's skills are adequate for rhythm interpretation; rhythm analysis and shock administration with an AED may result in prolonged interruptions in chest compressions

self-adhesive pads

the AHA recommends the use of ________________; using conductive materials (gel pads or soft-adhesive pads) during the defibrilation attempt reduces transthoracic impedance, or the resistance that chest structures have on electrical current

waveform capnography

the AHA recommends using quantitative ___________________ in intubated patients to monitor CPR quality, optimize chest compressions, and detect ROSC during chest compressions; although placement of invasive ponotors during CPR is not generally warranted, physiologic parameters such as intra-arterial relaxation pressures and central venous oxygen saturation, when available, may also be helpful for optimizing CPR and detecting ROSC animal and human studies indicate that PETCO2, CPP, and SCVO2 monitoring provides valuable information on both the patient's condition and the response to therapy; most important, PETCO2, CPP, and SCVO2 correlate with cardiac output and myocardial blood flow during CPR; when chest compressions fail to achieve identified threshhold values, ROSC is rarely achieved; furthermore, an abrupt increase in any of these parameters is a sensitive indicator of ROSC that can be monitored without interrupting chest compressions although no clinical study has examined whether titrating resuscitative efforts to physiologic parameters improves outcome, it is easonable to use these patameters, if available, to optimize compressions and guide vasopressor therapy during cardiac arrest

earlier defibrillation

the ___________________- occurs, the higher the survival rate; when VF is present, CPR can provide a small amount of blood flow to the heart and brain but cannot directly restore an organized rhythm; the likelihood of restoring a perfusing rhythm is optimized with immediate CPR and defibrillation within a few minutes of the inital arrest

adult cardiac arrest algorithm

the _____________________ is the most important algorithm to know for adult resuscitation; this algorithm outlines all assessment and management steps for the pulseless patient who does not intially respond to BLS interventions, including a first shock from an AED; the algorithm consists of the two pathways for a cardiac arrest: a shockable rhythm (VF/ pulseless VT) a nonshockable rhythm (asystole/PEA)

cardiac arrest treatment sequences

the adult cardiac arrest circular algorithm summarizes the recommended sequence of CPR, rhythm checks, shocks, and delivery of drugs based on expert consensus; the optimal number of cycles of CPR and shocks required before starting pharmacological therapy remains unknown; note that rhythm checks and shocks are organized around 5 cycles of compressiosn and ventilations, or 2 minutes if a provider is timing the arrest

deliver 1 shock

the appropriate energy dose is determined by the identity of the defibrillator- monophasic or biphasic; if you are using a monophasic defibrillator, give a single 360 J shock; use the same energy dose for subsequent shocks; biphasic defibrillators use a variety of waveforms, each of which is effective for terminating VF over a specific dose range; when using biphasic defibrillators, providers should use the manufacturer's recommended energy dose (e.g. inital dose of 120 to 200 J); many biphasic defibrillator manufactureres display the effective energy dose range on the face of the device; if you do not know the effective dose range, deliver the maximal energy dose for the first and all subsequent shocks if the initial shcok termintes VF but the arrhythmia recurs later in the resuscitation attempt, deliver subsequent shocks at the previously successful energy level immediately after the shock, resume CPR, beginning with chest compressions; give 2 minutes of CPR

high-performance team

the guidelines recommend that healthcare providers tailor the sequence of rescue actions based on the presumed etiology of the arrest; moreover, ACLS providers functioning within a high-performance team can choose the optimal approach for minimizing interruptions in chest compressions with passive oxygen insufflation and airway adjuncts, compression-only CPR in the first few minutes after arrest, and continuous chest compressions with asynchronous ventilation once every 6 seconds with the use of a bag-mask device, are a few examples of optimizing CCF and high-quality CPR; a default compression to ventilation ratio of 30:2 should be used by less trained healthcare providers or if 30:2 is the established protocol

collapse to defibrilation

the interval from ______________________ is one of the most importnat determinants of survival from cardiac arrest; early defibrillation is critical for patients with sudden cardiac arrest for the following reasons: a common initial rhythm in out-of-hospital witnessed sudden cardiac arrest is VF; pulseless VT rapidly deteriorates to VF; when VF is present, the heart quivers and does not pump blood electrical defibrillation is the most effective way to treat VF (delivery of a shock to stop the VF) the probability of successful defibrillation decreases quickly over time VF deteriorates to asystole if not treated

end-tidal CO2

the main determinant of PETCO2, during CPR is blood delivery to the lungs; persistently low PETCO2 values less than 10 mmHg during CPR in intubated patients suggests that ROST is unlikely; if PETCO2 abruptly increases ot a normal value of 35 to 40 mmHg, it is reasonable to consider this an indicator of ROSC if hte PETCO2 is less than 10 mmHg during CPR, it is reasonable to try to improve chest compressions and vasopressor therapy

steroids in cardiac arrest

the same 2 RCTs provided evidence that the use of methylprednisone and vasopression in addition to epinephrien improved ROSC rates compared with the use of placebo and epinephrine alone in OHCA, steroids have been evaluaed in 1 RCT and 1 observational study; in thse studies, steroids were not bundled as they were in the IHCA but studied as a sole treatment; when dexamethasone was given during cardiac arreset, it did not improve survival to hospital dishcarge or ROSC or survival to discharge, as compared with placebo; the observational study showed no benfit in survival to discharge but did show an association of improved ROSC with hydrocortisone compared with no hydrocortisone in light of the data presented, no recommendation can be made on the routine use of steroids alone in IHCA; however, the combination of intra-arrest vasopressin, epineprhine, and methylprednisolone and postarrest hydrocortisone may be considered for IHCA patients; for OHCA patients, use of steroids during CPR is of uncertain benefit

high-quality CPR

the success of any resuscitation attempt is built on a strong base of __________________ and defibrillation when required by the patient's ECG rhythm; to improve care, leaders must assess the performance of each system component; only when performance is evaluated can participants in a system effectively intervene to improve care; this process of quality improvement consists of an iterative and continuous cycle of: systematic evaluation of resuscitation care and outcome benchmarking with stakeholder feedback strategic efforts to address identified deficiencies

steroids in cardiac arrest

the use of ____________________ has been assessed in both the out-of-hospital and in-hospital settings; in IHCA, steroids were combined with a vasopressor bundle or cocktail of epineprhine and vasopressin in an intial randomzied control trial involving 100 IHCA patients, the use of a combination of methylprednisolone, vasopressin, and epinephrine during cardiac arrest and hydrocortisone after ROSC for those with shock significantly improved survival to hospital discharge compared with the use of only epinephrine and placebo; in a subsequent study published in 2013, 136 of 268 patients with IHCA, the same combinatio nof methlyprednisolone, vasopressin, and epinephrine during cadiac arrest (and hydrocortisone in those with post-ROSC shock), significantly improved the survival to discharge with good neurologic outcome compared with only epinephrine and placebo

clearing for defibrillation

to ensure safety during defibrillation, always announce the shock warning; state the warning firmly and in a forceful voice before delivering each shock (this entire sequence should take less than 5 seconds; clear, shocking -check to make sure you are clear of contact with the patient, the stretcher, or other equipment -make a visual check to ensure that no one is touching the patient or stretcher -be sure oxygen is not flowing across the patient's chest when pressing the shock button, the defibrilator operation should face the patient, not the machine; this helps to ensure coordination with the chest compressor and no verify that no one resumed contact with the patient; you do not need to use these exact words, but you must warn others that you are about to deliver shocks and that everyone must stand clear of the patient

ultrasound use in cardiac arrest

ultrasound may be applied to patients receiving CPR to help assess myocardial contractility and to help identify potentially treatable causes of cardiac arrest, suc has hypovolemia, pneumothorax, pulmonary thrombombolism, or pericardial tamponade; however, it is unclear whether important clinical outcomes are affected by the routine use of ultrasound among patients experiencing cardiac arrest; if a qualified sonographer is present and use of ultrasound does not interfere with the standard cardiac addest treatment protocol, then ultrasound may be considered as an adjunct to standard patient evaluation

extracorpreal membrane oxygenation

while there are currently no data from RCTs on the use of ECPR for cardiac arrest, evidence reviewed for the 2015 AHA guidelines update for CPR and ECC suggests a benefit to survival and favorable neurologic outcome with the use of ECPR when compared with conventional CPR in patients with refractory cardiac arrest in settings where ECPR can be rapidly implemented, providers may consider its use among select cardaic arrest patients with potentially reversible causes of cardiac arrest who have not responded to inital conventional CPR

vasopressors

while there is evidence that the use of _______________ favors initia lresuscitation with ROSC, research is still lacking on the effect of the routine use of vasopressors at any stage during management of cardiac arrest on the rates of survival to hospital discharge