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🌱 來自: Huppert’s Notes
Approach to Managing a Patient with Cardiac Arrest, aka “Code Blue”🚧 施工中
Approach to Managing a Patient with Cardiac Arrest, aka “Code Blue”
• Three key principles:
- Confirm code status
- Provide high-quality chest compressions with minimal interruptions
- Determine whether patient has a “shockable” rhythm (VT/VF) and shock EARLY if possible
• Approach to code leading:
- The approach to code leading varies from provider to provider; however, one approach is to consider the code as having three phases: An initial phase focusing on setting up conditions for success (i.e., backboard, access, etc.) and establishing a rhythm for the code team, a second phase focused on establishing the etiology of the arrest, and a post-arrest phase.
Phase 1: Initial management and establishing a cardiac rhythm
Establish your and team members’ roles
- Introduce your role clearly: “My name is _____ and I am the code leader.”
- Gather crucial information: “Does the patient have a pulse? What is their code status?”
- Identify the team and delegate tasks:
• Chest compressions, airway management, getting adequate IV access, performing critical diagnostics
• Designate: 1) “Code whisperer” to help the code leader/assist in crowd control; 2) Timekeeper/medication recorder; 3) Person to oversee medication administration (often a clinical pharmacist if available)
Chest compressions
- Place backboard and initiate chest compressions right away
- Compressions should be 2 inches deep (~5 cm) and performed at a rate of 100–120 compressions per minute. Allow for full chest recoil to promote venous return to the heart
- Identify additional providers who can switch in for subsequent rounds of chest compressions
- Minimize interruptions, as it takes several compressions to reach adequate perfusion pressure to vital organs
ECG leads/pads
- When the patient is on monitor, pause compressions briefly to do a rhythm check
- If Vfib/Vtach is detected, set up to perform an early shock per Advanced Cardiac Life Support (ACLS) algorithms
Airway management
- Identify who is in charge of the airway (often an anesthesiologist)
- Determine if advanced airway management is needed, such as endotracheal intubation
- Avoid overventilating the patient, as this will increase intrathoracic pressure and reduce preload
• Goal of 10 breaths per minute per ACLS algorithm with an advanced airway in place
Access
- Obtain IV access. If unable to obtain robust IV access, then obtain intraosseous (IO) access.
Medications
- Give medications per ACLS algorithm
• For either PEA or Vfib/Vtach arrest, give 1 mg epinephrine right away and then every 3–5 minutes
• For Vfib/Vtach, also give amiodarone
- Consider fluid bolus unless concern for cardiogenic shock
- Consider 1 gram calcium chloride, 2–3 amps bicarb, 1 gram magnesium sulfate, 1 amp D50
Managing the room
- Summarize out loud frequently: Review patient one-liner, ACLS algorithm being used (e.g., “This is a 50yo man with CAD; we are in pulseless VT”)
Phase 2: Diagnostics and determining etiology of arrest
Use the knowledge in the room
- Talk through “Hs/Ts” for PEA arrest (Table 3.2), invite thoughts from others in the room
TABLE 3.2 • Etiologies and Management for PEA and Vfib/Vtach Arrests
End tidal CO2 (ETCO2)
- If EtCO2 >10–20 mmHg, then chest compressions are adequate
- If EtCO2 <10 mmHg, assess if chest compressions can be improved and/or consider reasons for poor ventilation and V/Q mismatch, such as PE
- If ROSC (Return of Spontaneous Circulation) is achieved, a sudden rise to >35–45 mmHg will typically occur, reflecting improved pulmonary perfusion and gas exchange
POCUS
- Can be used to help identify certain etiologies such as tamponade or pneumothorax
- Presence of right heart strain can suggest PE
Labs
- ABG with electrolytes/lactate, CBC, CMP, coags, type and cross, point-of-care glucose, troponin
Review existing data
- Ask a colleague to review the patient’s chart to learn more about comorbidities, check recent labs, check ECG for QTc, review telemetry prior to the event, call primary team and update the patient’s family
Phase 3: Post-arrest care and debriefing
Post arrest care
- Determine if ROSC obtained with return of pulse and/or sudden rise of EtCO2 to >35–45 mmHg
- Assess mental status and responsiveness
• If not responsive, intubate to protect airway (if not already done) and consider targeted temperature management (TTM)
- If patient completely responsive, then do not need to cool
- If any doubt, consult neurology for evaluation and consideration of TTM
- Assess hemodynamics: Give vasopressors and/or fluids to maintain MAP goal
• MAP goal often >75 mmHg due to malfunctioning cerebral autoregulatory mechanisms
• Etiology of low MAP can be multifactorial: Post-arrest vasodilation from cytokine storm, transient reduction in cardiac function, and possibly infectious etiology, depending on the clinical context
- Ensure adequate sedation and pain management, especially when intubated
- Pulmonary optimization:
• Normocapnia with goal PCO2 35–45 mmHg
• Normoxia often SpO2 92–96% or PaO2 80–150 mmHg
- Obtain diagnostics:
• Labs: POC glucose, CBC, CMP, coags, lactate, troponin, cultures, urine tox
• Other studies: ECG, CXR, POCUS, consider CT scans (NCHCT, CTPE, CTAP)
- Determine disposition: ICU for most patients, cardiac catheterization lab if any concern for STEMI or other primary cardiac etiologies
- Notify family, next of kin, or other surrogate decision makers
- Notify attending(s)
- Write a code note
- Post-code debrief, ask for feedback
Targeted Temperature Management (TTM)
- Variable institutional practices about goal temperature, 33°C vs. 36°C given ongoing studies and debate about optimal goal
- Goal of avoiding hyperthermia is major driver to these protocols regardless of temperature goal
- Complications of cooling and rewarming: Hemodynamic changes, electrolyte shifts, coagulopathy
- TTM applied regardless of initial cardiac rhythm
- Protocol: Cool for 24 hours (from initiation), then at hour 24 gradually increase temperature to 37°C with passive rewarming, then maintain normothermia thereafter
• Many institutions use internal cooling catheters, which are an effective means to reach targeted temperature
• External cooling can also be achieved with ice packs, cooling blankets, NG lavage, IV saline methods
- Antipyretics are useful to prevent shivering and to prevent fevers/hyperthermia during rewarming
- Adequate sedation and sometimes paralysis are needed to prevent shivering