SIMWARS - Drug Review

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Shock treatment for VF and pulseless VT

Biphasic 200J
Monophasic 360J

Epinephrine for VF and pulseless VT

Epi 1mg q3-5 IV/IO minutes

Alternatives to Epi for VF and pulseless VT

Vasopressin 40 units IV/IO (can replace first or second dose of Epi)
Amiodarone 300mg IV, can give second dose of 150mg IV

Vasopressin dose for VF and pulseless VT

40 units IV/IO (can replace first or second dose of Epi)

Amiodarone dose for VF and pulseless VT

300mg IV, can give second dose of 150mg IV

Drugs for asystole or PEA

Epi 1mg q3-5 minutes
Vasopressin 40 units (first or second dose of epi)---> has been shown to be more effective?

H's and T's

Hypovolemia
Hypoxia
Hydrogen ion excess (acidosis)
Hypo/ hyperkalemia
Hypothermia
Hypoglycemia
Tension PTX
Tamponade, cardiac
Toxins
Thrombosis, pulm
Thrombosis, coronary

How to judge ROSC

Pulse and BP
Abrupt, sustained increase in PETCO2 (typically >=40mmHg)
Spontaneous arterial pressure waves with intraarterial monitoring

Voltage for pulseless VT

Biphasic 200J
Monophasic 360J

Good CPR?

Push hard and fast (at least 100/min)
Minimize interruptions in compressions
Rotate compressor every two minutes
If ETCO2 <10 mmHg, attempt to improve CPR

Amiodarone dose for VF, pulseless VT

300mg IV can give 2nd dose of 150mg IV

Vasopressin dose for VF, pulseless VT, asystole

40 units IV/IO... can replace Epi for first or second dose.... may be especially useful for asystole.

ROSC... what needs to happen?

1. Optimize oxygenation
Titrate O2 down to SpO2 >93%
Do NOT hyperventilate... 10-12 breath/min
Consider advanced airway and capnography

2. Prevent hypotension (SBP<90)
IV/IO bolus
Consider vasopressor infusion
Treat reversible causes....

Vasopressor infusion for hypotension in the setting of ROSC... if a bolus doesn't work

Epinephrine: 0.1-0.5 mcg/kg/min... for a 70 kg adult 7-35mcg/min

Norepinephrine: 0.1-0.5 mcg/kg/min.... for a 70 kg adult 7-35mcg/min

Dopamine: 5-10 mcg/kg/min

Indications for therapeutic hypothermia in the setting of ROSC

Follows commands or not...if not, start cold fluids, cooling blankets...

ROSC... you've controlled hypotension, you've optimized oxygenation... you've assessed the need for hypothermia... what else should you do?

Suspect AMI... get an EKG... may need to get to cath lab. IF not, disposition to the

HR <60... what next?

Appropriate for patient?
IV, O2, and monitor
Only give oxygen if hypoxic
12 lead ECG if available....

Then assess if they are stable or unstable...

Definition of instability in the setting of bradycardia

Hypotension
Altered mental status
Signs of shock
Ischemic chest discomfort
Acute heart failure --> fluid overload

Bradycardic... but completely stable?

Monitor and observe

Bradycardic and unstable.... IVs, O2 (if needed), and monitor in place...

12 lead ECG if available...
Unstable? If so, administer Atropine 0.5mg bolus... repeat q3-5min up to 3 mg

Bradycardia... dose of Atropine

0.5mg bolus... repeat q3-5 minutes up to six times

Atropine didn't work for bradycardia

Transcutaneous pacing

Atropine and trancutaneous pacing didn't work for bradycardia, what next?

Start considering transvenous pacing... future cardiology consult...
Dopamine or Epinephrine infusion...

Dopamine 2-10mcg/kg/min, titrate to effect
Epinephrine 2-10mcg/kg/min, titrate to effect

Dopamine or Epinephrine infusion for bradycardia, doses?

Dopamine 2-10mcg/kg/min, titrate to effect
Epinephrine 2-10mcg/kg/min, titrate to effect

Atropine... when should you not use it, or reconsider its usage?

Useless in heart transplant patients (no vagal nerve stimulation)

Avoid relying on atropine in high grade AV blocks, go to beta agonists (Dopamine or Epinephrine) or pacing...

Use cautiously when suspecting ACS

Before transcutaneous pacing... what should you consider?

Sedation! Midazolam 2mg or so....

Tachycardia.... first steps

Assess if appropriate for patient, usually it is not if >150...Sinus or not?

IV, O2, monitor
Only give O2 if hypoxic...
Get an EKG...

Unstable or stable?
Wide or narrow?
Regular or irregular?

Before shocking someone who is talking to you, sedate with 2mg Versed.

Tachycardia, unstable patient, narrow regular, how to cardiovert?

Sedate with Versed 2mg if talking to you
Biphasic: 50-100J

Tachycardia, unstable patient, narrow irregular, how to cardiovert?

Sedate with Versed 2mg
Biphasic: 120-200J

Tachycardia, unstable patient, wide regular, how to cardiovert?

Sedate with Versed 2mg
Biphasic: 100J

Tachycardia, unstable patient, wide complex irregular, how to cardiovert?

If somewhat more conscious, sedate with Versed 2mg
Defibrillation dose...
Biphasic 200J
Monophasic 360J

Regular, monomorphic, narrow complex tachycardia, first drug treatment

Vagal maneuvers
Adenosine.... 6mg.. can repeat 12mg, and then 12 mg again...
Beta blockers, CCB....

Wide complex regular tachycardia... stable, or cardioversion isn't working

Amiodarone 150mg IV over 10min
Drip: 1mg/min x 6 hrs, then 0.5mg/min x 18 hours

Procainamide 20-50mg/min until arrhythmia suppressed, hypotension or QRS prolongation
Max dose 17mg/kg
Drip: 1-4 mg/min

Sotalol 100mg over 5 mins
Avoid if prolonged QT

Drug of choice in WPW, if they are relatively stable...

Procainamide 20-50mg/min until arrhythmia suppressed, hypotension, or QRS prolongation...
Max dose 17mg/kg
Drip 1-4mg/min

Otherwise, shock them for narrow regular complex tachycardia.

Very very first step for patient in apparent cardiac arrest

Shout for help / activate emergency response system

Big changes for pediatric bradycardia ACLS vs adult

CPR if HR <60 and poor perfusion

Epinephrine 0.01mg/kg (0.1ml/kg of 1:10,000 concentration) seems to be preferred over Atropine 0.02mg/kg.

Epi can be repeated every 3-5 minutes. May give ET dose of ten times the amount 0.1mg/kg if IV/IO not yet placed.

Atropine can be repeated once...

Transcutaneous paching and treatment of underlying causes, as always, crucial....

Dose of synchronized cardioversion for kids

Begin with 0.5-1J/kg.. if not effective, increase to 2 J/kg... sedate if needed, don't delay cardioversion though...

Adenosine dose for kids

0.1mg/kg rapid bolus
0.2mg/kg second dose...

Max second dose of 12mg

Treatment of relatively stable regular wide complex tachycardia in kids

Consider adenosine if rhythm regular and QRS monomorphic....

Amiodarone
Procainamide
Expert consultation

Amiodarone and Procainamdie doses for kids

Amiodarone IV/IO dose 5mg/kg over 20-60 minutes
Procainamide 15mg/kg over 30-60 minutes

Do not routinely administer Procainamide and Amiodarone together!!!

Vagal maneuers include...

Carotid massage... only one side
Cold water on face
Valsalva-ing...

SIRS Criteria

>=2 meets definition..

Temp >38 or <36
HR >90
RR >20 or PaCO2<32mmHg
WBC >12 or <4

Suspected sepsis patients, what labs?

Lactate!!
CBC, Chemistry panel
U/A
Cultures from all suspected infection places: Blood x2 most definitely, urine, sputum, wounds....
LP if suspecting meningitis....

Sepsis criteria

SIRS + suspected source of infection

Severe sepsis criteria

SIRS + suspected source of infection + MAP <65 after 2 L crystalloid

Initial resuscitation in sepsis

AMPLE History
Flag down EMS / family
Initial 20-30ml/kg isotonic fluid over 20 minutes
Source control!!!
Broad spectrum antibiotics..
Place a central line in the IJ or the subclavian
If SpO2 <90% on non-rebreather... consider intubation

Fluid strategy in sepsis patients beyond initial bolus...

Choose ONE:
Empiric fluid loading: May require at least 6 L fluid during first six hours

Dynamic IVC ultrasound: Keep giving 500-1000 boluses until there is <30% change in IVC diameter with inspiration if not intubated... or >12% if intubated... Probe goes just underneath the xiphoid, 1-2 cm to the patient's right, and then point toward the heart... should see the IVC through the hepatic window..http://www.youtube.com/watch?v=ndcJ4DjmWVY


CVP: Keep giving fluid until CVP>10mmHg if not intubated, or >14 mmHg if intubated...

Goal progression in EGDT for sepsis

CVP>10mmHg if not intubated, >14mmHg if intubated - fluids
Then
MAP>=65 mmHg or SBP>90mmHg - vasopressors, titrate toi effect, consider empiric steroids
Then
ScvO2 >70% - pRBC to Hct >30.. inotropes if that still isnt getting the Scvo2>70%....

Another goal to think about is lactate clearance... can repeat a lactate, and compare it to your baseline... Clearance by >=10% is great

If that doesn't work, start over... should be in the ICU by this point.

MAP equation..

MAP = (2*DBP + SBP)/3
There is a cheap and easy way to approximate this...SBP>90mmHg

Vasopressors for sepsis

Norepinephrine 2-20mcg/min
Phenylephrine 40-200mcg/min
Vasopressin 0.01-0.04 U/min (if on another Vasopressor)...
Epinephrine 2-20mcg/min

Also add steroids to your vasopressor... Dexamethasone 2mg IV q6h

Too high blood pressure for sepsis?

May occur if you push too many pressures...
Nitro drip to compensate...
Hydralazine

Inotropes for sepsis

USe to correct ScvO2 parameters....
Dobutamine 2.5-20mcg/kg/min (If HR <100 and SBP>100)

Antibiotics for sepsis

Consider consulting ED pharmacologist....

Unknown source - Pip/Tazo + Vancomycin + Amikacin...
IF PCN resistant - Ciprofloxacin + Vancomycin + Amikacin

Suspected anaphylaxis treatment

ABCs!!!
Airway esp important
B - may have lots of wheezing
C - Large bore IVs for fluid resuscitation...as well as IV epi
D -
E - look for venom sac, stinger, what have you....

Cornerstone of therapy: Epinephrine... everything else is secondary... 0.1-0.5mg SC/IM (IM in thigh is the best), and IV if severe...IV dose 0.1mg IV slowly over 5 minutes....infusion of 1-4 ug/min may prevent the need to repeat Epi injections frequently... Close monitoring...

Adjunct therapy:
Antihistamines: Diphenhydramine 25-50mg IM or slowly IV

H2 blockers: Cimetidine 300mg orally, IM, or IV


Corticosteroids - beneficial effects delayed at least 4-6 hours... methylprednisolone (Solu-Medrol).... 200mg or so...?

Bronchospasm a major feature? Inhaled beta-adrenergic agents --> albuterol

Disposition for an anaphylaxis patient who is stable...

Observe in the ED for a time...
Discharge with an Epipen!!

Airway in anaphylaxis

Early elective intubation is recommended for patients observed to develop hoarseness, lingual edema, stridor, or oropharyngeal swelling....

RSI in asthma or anaphylaxis in which bronchoconstriction is a notable feature

Ketamine 1-2mg/kg IV over 1-2 minutes (about 100mg)... or 4-5 mg/kg IM.
+
Succinylcholine 0.6-1.1mgkg IV - 100mg for average patient...

Intubate procedure

Preoxygenate with 100% O2 by nonrebreahter mask for at least 3 full, deep breaths... IF ventilation required, bag gnetly while cricoid pressure is applied...preoxygenate for up to four minutes if situation allows....

Sedate: midazolam OR etomidate...
- Midazolam 2mg for average size adult
- Etomidate 0.3mg/kg or 20mg for average adult
- If SBP low... etomidate > midazolam
- If bronchoconstriction - Ketamine! 1-2mg/kg or about 100mg IV

Head injury? Lidocaine 1.5mg/kg to reduce ICP...about 100mg for average adult...

Paralyze: Succinylcholine 1.5mg/kg IVP - 100mg average for adult...

Intubate!!! Narrate what you say for the team leader....Abort and return to oxygenation if:
- Thirty seconds have passed, and PO2 <91%
- HR falls below 60

After confirming intubation, get respiratory in there... otherwise, continue bagging... be sure to strap tube to patient's face...

How we should confirm intubation

Saw the tube go in....
Chest wall rise
Lack of gastric bubbling
Bilateral breath sounds
ETCO2 measurement
Continued PO2 readings in the high 90's

Patient becomes agitated after intubation....

Midazolam 1mg q1-2 minutes until patient is calm, BP drops, or max 10mg utilized....

If long transport is anticipated... consider administering vecuronium 0.1mg/kg... SEDATION STILL REQUIRED

FAST Exam

Curvilinear probe...

Pericardium: Just left of the xiphisternum and angled upwards under the costal margin.

Perihepatic (Rutherford-Morison): Right mid to posterior axillary line: between 11-12th rib

Perisplenic: Left posterior axillary line region between the 10th and 11th rib

Pelvic (cul de sac), pouch of douglas vs rectovesical pouch: Midline just superior to the symphysis pubis... sagital and transverse.

Ultrasound for pulmonary embolism

Linear probe - 7.5-10Mhz...

Normal: Visceral pleura slides along the parietal pleura --> air/tissue interface seen as comet-tail artifacts on ultrasound

Pneumothorax: Loss of sliding, comet-tail artifacts....

Can pick up PTX that a CXR might not!

http://www.youtube.com/watch?v=Xxdedx1HtHo

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