Sudden collapse at health club

Sudden collapse at health club!

Case Author: Howard A. Schwid, M.D.

Affiliation: University of Washington

Date of Last Modification: March 9, 2006

View Help > Instructions for step-by-step instructions to resuscitate this patient and use Anesoft ACLS Simulator 7.

Learning Objectives:

1. Describe the secondary ABCD survey.

2. Outline the steps of the V Fib algorithm that follow the first shocks.

3. Describe methods to confirm correct positioning of the endotracheal tube.

4. Describe rates of chest compression and ventilation for adult CPR.

5. Discuss the role of epinephrine for the treatment of ventricular fibrillation.

6. Discuss the role of vasopressin in the treatment of ventricular fibrillation.

Secondary ABCD Survey:

A. Airway - assess and manage - place an endotracheal tube.

B. Breathing - assess and manage - positive pressure ventilation with supplemental oxygen.

C. Circulation - assess and manage - obtain IV access (in IV/Meds), administer medications.

D. Differential Diagnosis - assess and manage - search for and treat reversible causes of the arrhythmia.

Ventricular Fibrillation Algorithm:

1. If the patient does not respond to the initial electrical defibrillation attempts, you must treat hypoxia. Establish an airway (intubation is ideal), ventilate with supplemental oxygen, and perform chest compressions.

2. Reassess to ensure adequate ventilation and pulse with CPR.

3. Establish intravenous access. Try to interrupt CPR as little as possible. Peripheral IV access is adequate.

4. Epinephrine or vasopressin should be administered to increase perfusion pressure. Administer epinephrine (1 mg IV bolus) or vasopressin 40 U IV and shock again. Repeat epinephrine every 3-5 minutes.

Confirmation of Endotracheal Tube Position:

1. Listen to breath sounds and over the epigastrium and observe for chest wall movement to rule out esophageal or mainstem intubation. If there is any doubt about esophageal intubation, use an end-tidal CO2 or the esophageal detector device.

2. End-tidal CO2 should be present if the lungs are being ventilated. Ventilation of the stomach can produce CO2, especially if the patient recently ingested carbonated beverages. CO2 from the stomach rapidly disappears. If CO2 delivery to the lungs is low due to low blood flow there may be little end-tidal CO2 even with correct tracheal tube placement. The CO2 monitor can thus be used as an indicator of effective chest compressions.

3. The esophageal detector device creates a negative pressure on the endotracheal tube. If the tube is in the trachea, gas will be pulled from the lungs and the detector will reinflate. If the tube is in the esophagus, the esophageal mucosa will be pulled into the tube and the detector will remain collapsed.

4. When in doubt try both end-tidal CO2 and esophageal detection devices.

Epinephrine in V Fib Treatment:

1. Epinephrine is administered as a vasoconstrictor to improve coronary and cerebral perfusion.

2. There is indeterminate evidence that it is helpful.

3. The recommended dose is 1 mg IV every 3-5 minutes.

4. Higher doses are acceptable but may be harmful.

Vasopressin in V Fib Treatment:

1. Vasopressin is an acceptable alternative vasoconstrictor during ventricular fibrillation resuscitation.

2. The recommended dose is 40 U IV push, once.

3. If there is no response 5-10 minutes after vasopressin, it is acceptable to use epinephrine boluses.