ANESTHESIOLOGY

CARDIOVASCULAR DRUGS FOR RESUSCITATION

Kristine R. Gonzaga, MD, DPBA, FPSA
First Loop | 1 August 2020

Note. Green – Facilitator’s notes and comments • Oxygenate

TABLE OF CONTENTS
I. Components of Systemic Approach for ACLS • Monitor
A. Conscious and Breathing
B. Unconscious: BLS Survey • IV/IO
C. Simplified ACLS Cardiac Arrest Algorithm • Treat
D. Return of Spontaneous Circulation (ROSC)

1. Oxygenate
• Provide supplemental oxygenation
• If the oxygen is less than 94% (90% for acute coronary syndrome),
provide supplemental oxygen
o Nasal cannula 2-4 LPM
o Simple face mask 6-10 LPM
o Non-rebreather mask 11-15 LPM
▪ Only one that will give you an FiO2 of 100%.
▪ Provides O2 via high flow.
▪ Pressure in the mask is lower than the atmospheric air (21%
O2) pressure. Excess will go out.

FiO2 of Supplemental Oxygen Delivery

• Nasal cannula – Low flow
• If you want to give higher dose of oxygen, use a nonrebreathing face
(See appendix for clearer view.) mask.

COMPONENTS OF SYSTEMIC APPROACH FOR ACLS Device Flow Rates Delivered O2

Nasal cannula 1 L/min 21%-24%
2 L/min 25%-28%
3 L/min 29%-32%
4 L/min 33%-36%
5 L/min 37%-40%
6 L/min 41%-44%
Simple oxygen 6-10 L/min 35%-60%
face mask
Face mask with O2 6 L/min 60%
reservoir 7 L/min 70%
(nonrebreathing 8 L/min 80%
mask) 9 L/min 90%
10-15 L/min 95%-100%

2. Monitor
• Hook the patient to the cardiac monitor
(See appendix for clearer view.)

• Unconscious, not breathing, and pulseless, do BLS survey.

• Unconscious, not breathing, pale, do BLS survey.
• Conscious, breathing, talking to you, do ACLS Survey.
• Initial Impression
o Consciousness
o Breathing
o Color
• Primary Assessment (ABCDE)
o Airway
o Breathing (Respiratory rate, work of breathing, SpO2, breath
sounds)
o Circulation (Heart rate, blood pressure, central and peripheral 3. IV/IO (Vascular Access)
pulses, CRT) • Establish a vascular access
o Disability (AVPU/GCS, pupillary response, glucose) • Intravenous – Antecubital veins
o Exposure (Temperature, bleeding, burns, trauma, medical alert o Easiest to access
bracelet) o If you cannot insert after 2 attempts in a critically ill patient, do
• Secondary Assessment (SAMPLE, Hs and Ts) intraosseous access since the blood vessels will constrict in a
o Signs and symptoms hypotensive patient.
o Allergies • Intraosseous – Humeral head, sternum, distal femur, proximal tibia,
o Medications distal tibia
o Past medical history o Contraindications: Crush injuries on the site, infections on the
o Last meal site, degenerative bone disorder (osteogenesis imperfecta), if you
o Events have previously inserted on that bone (e.g., If you inserted already
o Hs and Ts but failed on the right proximal tibia, do not attempt to do it in the
right distal tibia. Use the left side instead)
A. Conscious and Breathing
• Visualize, verbalize, vital signs 4. Treat
o Visualize: Is he stable? Is he in cardiorespiratory distress? • Identify and manage the patient’s ECG rhythm
o Verbalize: Ask the patient how he is feeling, his chief complaint.
o Vital signs: HR, BP, RR, T, SpO2

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Sinus Bradycardia Supraventricular Tachycardia

• Rhythm is slow (<60/min) • Rhythm is fast (>160/min)
• P waves are present • P waves are absent
• Each P wave is followed by a regularly occurring QRS • QRS is regularly occurring and narrow in configuration
• PR intervals are normal (≤0.2 s)

Treatment for Fast Rhythms (Narrow Complex Tachycardia)

Sinus Bradycardia with 1st Degree AV Block
• All fast rhythms should be treated since the heart cannot go fast for
• Fixed, prolonged PR interval (>0.2 s) too long.
• No dropped beats • Stable
o Physiologic
▪ Vagal maneuver
▪ Carotid massage
• If there are no contraindications (history of coronary artery
disease, coronary bruit), do it unilaterally for 5-10
Sinus Bradycardia with 2nd Degree AV Block Type 1 seconds.
• Dropped beats are present ▪ Cough/strain
• Progressive lengthening of PR interval until dropped beat • If there is a contraindication for carotid massage
o Pharmacologic
▪ If physiologic vagal maneuver is ineffective to convert fast
rhythm.
▪ Adenosine
• Rapid IV bolus (because of its short half-life)
• Initial dose: 6 mg
Sinus Bradycardia with 2nd Degree AV Block Type 2
• Second dose: 12 mg
• Dropped beats are present
• Unstable (SBP < 90 mmHg, stable SVT becomes unresponsive to
• Constant and fixed PR interval until dropped beat
pharmacologic agents)
o Sedate (if time permits)
▪ Diazepam
▪ Midazolam
▪ Etomidate
▪ Propofol
Sinus Bradycardia with 3rd Degree AV Block o Synchronized cardioversion
• Both atrial rhythm and ventricular rhythm are regular but independent ▪ Energy dose
(dissociated) from one other • Atrial fibrillation – 120-200 J
• SVT – 50 J initial (next dose is escalating, 100, 150, 200)

Ventricular Tachycardia with Pulse

• Rhythm is fast (>160/min)
• P waves are absent
• QRS is regularly occurring and wide in configuration
Treatment for Slow Rhythms (Symptomatic and Unstable)
• Do not treat all slow rhythms. In some people, they may have normal
rhythms (athlete, old persons using beta blockers).
• However, if they are symptomatic (dizziness, difficulty of breathing),
have unstable BP (SBP < 90 mm Hg) and have slow rhythms, treat.
• All Trained Dogs Eat
• Atropine sulfate
o Dose: 0.5 mg Treatment for Fast Rhythms (Wide Complex Tachycardia)
o Max: 3 mg
• Stable
o Total: 6 doses
o Seek expert consultation
o Time interval: Every 3 to 5 minutes
o You can try physiologic maneuvers, but usually is ineffective.
o Low degree blocks are responsive to atropine
o Pharmacologic
▪ Sinus bradycardia
▪ Amiodarone infusion
▪ 1st degree AVB
• Dose: 150 mg
▪ 2nd degree AVB Type 1
o Responds by increasing heart rate to achieve an SBP of at least • Duration: 10 mins (for 2 doses)
90 mm Hg • Unstable
o High degree blocks (2nd degree AVP Type 2 and 3rd degree AVB) o Sedate
are unresponsive to atropine and makes the heart more ▪ Diazepam
bradycardic ▪ Midazolam
• Transcutaneous pacing (TCP) ▪ Etomidate
o Put pacer pads ▪ Propofol
o Set rate o Synchronized cardioversion
o Set mAMP ▪ Energy dose
o Pace (achieve complete capture) • V Tach – 100 J initial (if ineffective, give next dose at a
o Confirm pulse higher level, 150, 200)
• Dopamine infusion
o Dose: 2-20 mcg/Kg/min B. Unconscious: BLS Survey
• Epinephrine infusion • Responsiveness: No response?
o Titrate to patient response • Ask for help: Help! Someone, help!
o Dose: 2-10 mcg/min or 0.1-0.5 mcg/Kg/min

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• Carotid pulse simultaneously with breathing: 5-10 seconds. No 1. Ventricular Fibrillation

pulse? No or abnormal breathing? • P waves are absent
• Call ERS. Activate emergency response and get an AED/defibrillator. • QRS are present and highly disorganized and chaotic
• Start high quality CPR

1. Critical Elements of a High-Quality CPR

• Push hard: 2-2.4 in (5-6 cm)
• Hand technique: 2 hands (one on top of the other) on the lower half
of the sternum
• Push fast: 100-120/min 2. Pulseless Ventricular Tachycardia
• Allow complete chest recoil. Avoid leaning on the chest between • Rhythm is fast (>160/min)
compressions. • P waves are absent
• Minimize interruptions. Limit to <10 s • QRS is regularly occurring and wide in configuration.
• Avoid excessive ventilation. 2 breaths (using bag-mask device) • Patient is pulseless.
after every 30 compressions
• Priority in cardiac arrest: Compressions (C, then A and B)

Chest Compression Fraction (CCF)

• One of the most important factors for achieving successful outcomes
is to minimize the frequency and duration of interruptions in chest
compressions, thereby maximizing coronary perfusion and blood flow Time-Sensitive Model of Ventricular Fibrillation
during CPR • Electrical Phase
o First 5 minutes of arrest
• When is CPR often interrupted or delayed? o Early defibrillation is critical
o Rescue breaths o High oxygen consumption rapidly depletes myocardial ATP
o Pulse check • Hemodynamic Phase
o Rhythm analysis o Next 5 minutes
o Defibrillation o Perfusing the myocardium and brain with oxygenated blood is
• Measurement of the percentage of time in which chest compressions critical (effective chest compressions help replete or delay
are done by rescuers during a cardiac arrest reductions in ATP by generating adequate coronary perfusion to
restore myocardial blood flow)
𝑇𝑜𝑡𝑎𝑙 𝑡𝑖𝑚𝑒 𝑜𝑓 𝑐ℎ𝑒𝑠𝑡 𝑐𝑜𝑚𝑝𝑟𝑒𝑠𝑠𝑖𝑜𝑛𝑠 (ℎ𝑎𝑛𝑑𝑠 − 𝑜𝑛 𝑡𝑖𝑚𝑒) • Metabolic Phase
𝐶𝐶𝐹 = o Beyond 10 minutes
𝑇𝑜𝑡𝑎𝑙 𝑟𝑒𝑠𝑢𝑠𝑐𝑖𝑡𝑎𝑡𝑖𝑜𝑛 (𝑐𝑜𝑑𝑒) 𝑡𝑖𝑚𝑒
o Ischemic injury to the heart is so great that is not clear what
interventions will be successful

3. Shock First vs CPR First

• Adult witnessed cardiac arrest and AED/defibrillator is immediately
available, shock first. Then, start CPR.
• Adult did not witness cardiac arrest or AED is not immediately
available, start CPR while AED is being retrieved and while it is being
applied to the victim
• Target: 0.6 – 0.8
o In a 10-minute code: 4. Shockable Arrest Rhythms
360 𝑠 480 𝑠 • How much shock you give depends on the defibrillator
0.6 = 0.8 = o Monophasic: 300J
600 𝑠 600 𝑠
o Biphasic: 200J
o In a 2-minute code: • After first shock, do not give any drugs because the primary treatment
72 𝑠 96 𝑠 for shockable rhythms is shock
0.6 = 0.8 =
120 𝑠 120 𝑠 • Epinephrine for its α2 effect for vasoconstriction.
o Diluted for faster delivery to the periphery.
2. CPR with an Advanced Airway (Intubated Patients)
• In the time of COVID, it is recommended to intubate the patients before
you start compressions.
• Chest compressions: Continuous, uninterrupted. At 100-120/min
• Ventilation: 1 breath every 6 seconds (10 breaths/min)
• Why not hyperventilate?
o ↑ Intragastric pressure: Prone to aspiration (BMV)
o ↑ Intrathoracic pressure: ↓ Venous return
o ↓ Carbon dioxide in the brain: Cerebral vasoconstriction (↓ blood
flow)

C. Simplified ACLS Cardiac Arrest Algorithm

(See appendix for clearer view.)

5. 2018 AHA Focused Update on ACLS Use of Antiarrhythmic

Drugs During and Immediately and After Cardiac Arrest
• During resuscitation from adult VF or pulseless VT cardiac arrest
o Amiodarone and lidocaine recommendation
▪ Amiodarone or lidocaine may be considered for VF or
pulseless VT that is unresponsive to defibrillation. These
drugs may be particularly useful for patients with witnessed
arrest, for whom time to drug administration may be shorter
(Class IIb; Level of Evidence B-R).
(See appendix for clearer view.)

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• Lidocaine is an alternative.
o First dose: 1-1.5 mg/Kg
o Second dose: 0.5-0.7 mg/Kg
o Magnesium recommendation
▪ The routine use of magnesium for cardiac arrest is not
recommended in adult patients (Class III: No benefit; Level
of Evidence C-LD). Magnesium may be considered for
torsade de pointes (i.e., polymorphic VT associated with
long QT interval) (Class IIb; Level of Evidence C-LD).

1. 5-Point Auscultation
• Primary confirmation of endotracheal tube placement
• Start at epigastric area. There should be no gurgling sounds. If there
are gurgling sounds, the tip of ETT has entered the esophagus or
stomach. Remove and reinsert ETT.
• Equal sounds on the bases and apices.
o If more on the right, it’s on the airway but entered the right main
bronchus. Deflate a little, then pull out a few cm until equal.

(See appendix for clearer view.)

6. Asystole
• Flatline

2. Waveform Capnography
• Secondary confirmation by detecting carbon dioxide
7. Pulseless Electrical Activity (PEA) • Uses:
• Rhythm is regular o Confirms correct placement of advanced airway
• P waves are present o Reflects effectiveness of chest compressions during CPR
• Each P wave is followed by a regularly occurring QRS ▪ Have at least 10 mm Hg
• Patient is pulseless ▪ If 5-8 mm Hg compressions are ineffective
• Any organized rhythm without a pulse ▪ If 35-40 mm Hg, there is ROSC
o Predicts return of spontaneous circulation

Treatment for Asystole and PEA

• Start high-quality CPR
• Give epinephrine (every 3 to 5 minutes or every other cycle)
• Treat reversible causes of cardiac arrests (Hs and Ts)
o The earlier you identify, the greater the chance that the patient will
revive.

Upstroke is exhalation. Downstroke is inhalation.

3. Rescue Breathing

Airway Devices Ventilation during Ventilation during

Cardiac Arrest Respiratory Arrest
Bag-mask 2 ventilations after
every 30 chest
1 ventilation every
compressions
5-6 seconds
Any advanced 1 ventilation every 6
(10-12 breaths/min)
airway seconds
(10 breaths/min)

(See appendix for clearer view.)
D. Return of Spontaneous Circulation (ROSC)
• Priorities:
o Optimize oxygenation and ventilation by managing airway and
breathing
▪ If not breathing spontaneously, give advanced airway.
4. Addressing Circulation
• If there are no contraindications, give fluids first.
o 1-2 PNSS/PLRS
• Monitor VS. If it has not reached at least an SBP of 90 mm Hg or has
renal or cardiac problems, add or start vasopressors.

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(See appendix for clearer view.)

5. Targeted Temperature Management (TTM)

• If patient appears comatose
• Cool down the brain to decrease metabolism, allowing the brain to rest
• Give 30 mL/Kg 4OC PNSS/PLRS for 30 minutes
• Targeted temperature between 32OC and 36OC selected and
achieved, then maintained constantly for at least 24 hours
• Improvement in neurologic outcome for those in whom hypothermia
was induced
• Do post arrest care after
o NGT to decompress the stomach
o Urinary catheter to check for urine output
o ECG
o Chest x-ray
o Insert central line
o Transfer patient to ICU

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