Code Blue in cardiac rehab

Code Blue in cardiac rehab

Recovery from asystole is unusual unless a treatable cause can be identified and treated promptly. In this simulated scenario, the patient will die no matter what you do during the resuscitation attempt. He suffered massive acute coronary thrombosis. The purpose of this simulation is to rehearse the management of asystole and force you to consider when to stop the resuscitative efforts.

Learning Objectives:

1. List the steps in treating asystole.

2. List steps to take prior to ceasing the resuscitation attempt.

3. List atypical clinical features that would prolong the resuscitation attempt.

Asystole Algorithm:

1. Administer hard and fast chest compressions and positive pressure ventilation with oxygen. Perform CPR with as few interruptions as possible. Obtain IV access. Peripheral IV access is acceptable.

2. Search for a treatable cause. Consider: 5 H's and 5 T's:

Hypovolemia Tablets (drugs)

Hypoxia Tamponade-cardiac

Hydrogen ion-acidosis Tension pneumothorax

Hyper/hypokalemia Thrombosis-coronary

Hypothermia Thrombosis-pulmonary

Hypoglycemia

3. The goal of treatment is to provide vigorous CPR, treat hypoxia, and identify and treat the cause of the asystole.

4. Epinephrine 1 mg IV push, repeat every 3-5 min. vasopressin 40 units can be substituted for one dose of epinephrine.

5. Consider administering Atropine 1 mg IV push, repeat every 3-5 min to total 0.04 mg/kg for asystole or a slow rate in pulseless electrical activity.

6. Transcutaneous pacing (TCP) is no longer recommended for asystole. Electrical defibrillation will not be effective for asystole.

7. Advanced airway management is not necessary unless bag and mask ventilation is inadequate. Tracheal intubation may be advisable if skilled personnel are present and intubation can be performed with only brief interruption of CPR.

Ceasing the Resuscitation Attempt:

Consider stopping the resuscitative efforts when asystole remains after:

1. Adequate CPR.

2. Adequate bag and mask ventilation with oxygen.

3. Tracheal intubation with confirmation of tube placement for inadequate bag and mask ventilation.

4. Obtained IV access.

5. Repeatedly administered epinephrine.

6. Continuously documented asystole for at least 10 minutes. Ruled out fine v fib.

7. The decision to stop resuscitative efforts is a matter of "clinical judgement and respect for human dignity". See reference below.

Prolong the Resuscitation Attempt:

Consider continuing the resuscitative efforts when asystole remains in the following situations:

1. Drowning

2. Hypothermia

3. Drug overdose

Reference:

1. 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, Part 7: Advanced Cardiovascular Life Support. Circulation 2005; 112: IV-61-IV-62.

2. Advanced Cardiovascular Life Support Provider Manual, American Heart Association, 2006: p 62.