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CLASSIFICATION OF THERAPEUTIC INTERVENTIONS IN CARDIOPULMONARY RESUSCITATION AND ECC

Class I
A therapeutic option that is usually indicated, always acceptable and considered useful and effective

Class II
A therapeutic option that is acceptable, is of uncertain efficacy and may be controversial
Class II A - A therapeutic option for which the weight of evidence is in favor of its usefulness and efficacy Class II B - A therapeutic option that is not well established by evidence but may be helpful and probably is not harmful

Class III
A therapeutic option that is not well established by evidence but may be helpful and probably is not harmful

DRUG THERAPY
Administration of drug during Cardiac Arrest Central vs. Peripheral Infusion Endotracheal drug administration Intraosseous access

CENTRAL VS PERIPHERAL INFUSION


PERIPHERAL
Antecubital or External Jugular peak drug level are lower circulation time is increased drug requires 1 - 2 min. to reach central circulation

CENTRAL VS PERIPHERAL INFUSION


PERIPHERAL
easier to learn fewer complications administered rapidly by bolus injection followed by a 20 ml bolus of IVF and elevation of the extremity

CENTRAL VS PERIPHERAL INFUSION


CENTRAL
more rapid arrival of drugs at the site of action sites:
jugular vein supraclavicular subclavian vein (less interruption of chest compression than the infraclavicular route) femoral vein (little cephalad flow during CPR) Umbilical vein (neonates) - below the skin level and a free flow of blood return on aspiration

CENTRAL VS PERIPHERAL INFUSION


CENTRAL
increased risk of complication are associated from patients who receive thrombolytic therapy one unsuccessful central attempt is a strong relative contraindication to initiation of thrombolyssis

ENDOTRACHEAL DRUG ADMINISTRATION


Adults
2 - 2.5X the recommended IV dose diluted in 10 ml of NSS or distilled water

Pediatrics
10X the recommended IV dose diluted in 1 - 2 ml of Normal or half normal saline

Neonates
optimal dosage in newborn unknown

ENDOTRACHEAL TUBE SIZING


Pedia
< 6 years old
Age in years divided by 3 + 3.5 = _____ mm I.D.

> 6 years old


Age in years divided by 4 + 4.5= _____ mm I.D.

ENDOTRACHEAL TUBE SIZING


Pedia
approximate tube that approximate little finger or RIGHT nostril measure the middle finger of patient in cm. (using cm marking of E.T. tube) corresponding measurement is the crude measurement of the I.D.

ENDOTRACHEAL TUBE LEVEL


Adult:
21 cm +/- 2 cm level of the upper incisor

Pedia:
Age in years divided by 2 + 12

ENDOTRACHEAL TUBE LEVEL


If nasotracheally intubated - add 3 cm at the level of nostrils Tip of Tube
Adults : Level of body of T3 Pedia : Level of body of T2

DRUGS ADMINISTERED THRU E.T.


Naloxone Atropine Valium Epinephrine Lidocaine

NALOXONE
Pedia
10 mcg (0.01mg)/kg/dose

Adults
400 mcg (0.4 mg)

ATROPINE
Pedia
10 mcg/kg/dose

Adults
250 mcg - 2 mg (antispasmodic) in single or divided doses 300 - 600 mcg IM, IV immediately before induction of anesthesia and in incremental doses for the treatment of bradycardia

VALIUM
Pedia
0.2 - 0.3 mg/kg/dose

Adult
5 - 10 mg

EPINEPHRINE
Pedia
0.01 mg/kg/dose First Dose:
1:10,000 = 0.1 cc or 0.01 mg/kg

2nd Dose (High Dose - Class I)


1:100 = 0.1 mg/kg q 3 - 5 min

EPINEPHRINE
Adults
1.0 mg in cardiac arrest
IV Dose
Standard (Class I) 0.5 - 1 mg q 3 - 5 min Intermediate Dose 2 - 5 mg q 3 - 5 min Escalating Dose 1 - 3 - 5 mg q 3 - 5 min

EPINEPHRINE
Infusion Drip
1 mg in 100 ml D5Water Initiate infusion at 2 and max. of 10 ug/min and titrated

EPINEPHRINE
Modified Rule of Six
weight in kg X 0.6 = mg to be incorporated in 100 cc IVF Stock Dose: 1 ml = 0.1 ug/min Infusion Dose: 0.1 ug/min titrated up to 1 ug/kg/min
Example: 5 kg Bwt 5 X 0.6 = 3 mg in 100 cc IVF or 7.5 mg in 250 cc Stock Dose : 1 ml = 0.1 ug/min Desired Dose : 0.2 ug 1ml = 60 ugtts :: 0.1 ug/min 1ml = 60 ugtts :: 0.2 ug/min : x = 12 ugtts/min

LIDOCAINE
Pedia
20 - 50 ug/kg/min

Adult
2 - 4 mg/min

INTRAOSSEOUS ACCESS
used to deliver rapid infusion
pressure infusion devices administering a bolus with a syringe attached to a three-way stopcock

Venous access cannot be achieved within 3 attempts or 90 seconds

INTRAOSSEOUS ACCESS
Intraosseous infusion needles
18 to 20 gauge spinal needle 14 - 20 gauge needle bone marrow needle

anterior tibial area 1-2 cm distal and medial to the tibial tuberosity
(proximal anterior tibial or distal femur bone marrow)

INTRAOSSEOUS ACCESS
avoiding the epiphysis not employed in a fractured extremity

DRUGS USED IN ADVANCED CARDIAC LIFE SUPPORT


Correction of Hypoxemia with Oxygen Therapy Intravenous Fluids Drugs that Control Heart Rhythm and Rate Drugs that Improve Cardiac Output and Blood Pressure

Correction of Hypoxemia with Oxygen Therapy (Class I)


Oxygen
increase arterial O2 tension and Hgb saturation Neonates - the hazard of administering too much O2 during brief period required for resuscitation should not be a concern

Correction of Hypoxemia with Oxygen Therapy (Class I)


BVMU
Pedia - self inflating bag 21% O2 10L/min w/out reservoir = 30 - 80% O2 10 - 15L/min with reservoir = 60 - 95% O2

Intravenous Fluids
Adults
Volume Expanders
whole blood crystalloid solutions colloid solutions

KVO = D5Water

Intravenous Fluids
Adults
PNSS
preferred infusion solution during cardiac arrest Hyperglycemia in cardiac arrest patients who survive is associated with worse neurological outcome Sodium overload is rarely encountered in normal saline

Intravenous Fluids
Adults
Volume administration is not recommended in routine cardiac arrest without indications of volume depletion
it may diminish blood flow to the cerebral and coronary circulation

Intravenous Fluids
Pediatrics
Volume Expanders
crystalloid solution colloid solution blood for severe acute hemorrhage

Intravenous Fluids
Pediatrics
Dextrose solutions should not be used in children (Class III) large volume of glucose containing IV solutions will result in:
hyperglycemia secondary osmotic diuresis potentially worse neurologic outcome.

Hypoglycemia is not a problem

Intravenous Fluids
Neonates
Volume expanders (Class I) - indicated when there is evidence or suspicion of acute blood loss with poor response to resuscitation Dosage : 10 ml/kg
NSS or PLR 5% Albumin saline or other plasma substitute O negative blood crossmatched with mothers blood

DRUGS THAT CONTROL HEART RHYTHM AND RATE


LIDOCAINE (Class IIB) ATROPINE VERAPAMIL MAGNESIUM

DRUGS THAT IMPROVE CARDIAC OUTPUT AND BLOOD PRESSURE


EPINEPHRINE DOPAMINE DOBUTAMINE DIGITALIS NITROGLYCERINE SODIUM NITROPRUSSIDE SODIUM BICARBONATE DIURETICS